Neurocritical Care最新文献

Background: The receptor tyrosine kinase AR4-type receptor in erythropoietin-producing hepatocellular carcinoma (EphA4) has been linked to disruption of the blood-brain barrier (BBB) and hemorrhagic transformation after acute ischemic stroke. Here, we explored whether EphA4 may be involved in parenchymal hematoma (PH) after ischemic stroke.

Methods: Data were analyzed from patients who were admitted to West China Hospital of Sichuan University within 48 h of stroke onset between January 2017 and December 2019. EphA4 levels in serum were measured within 24 h after admission, and baseline computed tomography perfusion was performed immediately upon admission. Potential relationships of EphA4 levels or ipsilateral flow extraction product (FED) with occurrence of PH were explored using logistic regression.

Results: Of the 578 patients (337 men) analyzed, who were a median age of 69 years old, 56 (9.69%) developed PH. Serum EphA4 levels were higher in patients with PH than in those without PH (44.96 vs. 37.86 ng/mL, P = 0.036). After adjustment for confounders, higher serum EphA4 levels (≥ 32.21 ng/mL) were significantly associated with PH (odds ratio [OR] 3.84, 95% confidence interval [CI] 1.66-8.90, P = 0.002). Among the 230 patients in whom brain perfusion was analyzed using computed tomography perfusion, ipsilateral FED was significantly associated with PH after adjusting for confounders (OR 2.43, 95% CI 1.63-3.63, P < 0.001). The two parameters of EphA4 level and ipsilateral FED interacted in their association with PH (P_interaction = 0.037): higher EphA4 level was associated with PH in those with higher ipsilateral FED (OR 1.04, 95% CI 1.01-1.07, P = 0.006), not in those with lower FED.

Conclusions: Elevated EphA4 levels in serum are associated with higher risk of PH after ischemic stroke, especially among patients showing greater permeability of the BBB as reflected in higher ipsilateral FED on computed tomography perfusion.

Background: Early postoperative cerebral infarction (ePCI) following spontaneous intracerebral hemorrhage (ICH) is a severe complication. This study aimed to develop and validate a cisterns and cortical sulci effacement (CCSE) score for predicting ePCI and to compare its predictive performance with that of established clinical scoring systems.

Methods: Data on spontaneous ICH from two centers were retrospectively analyzed. The visibility of 10 cisterns and the left/right cortical sulci was assessed on preoperative computed tomography scans (scored as 0 = visible, 1 = not visible), and the total sum constituted the CCSE score. Interrater and intrarater reliability were assessed using Cohen's κ coefficient. Logistic regression and subgroup analyses were conducted to explore the association between CCSE and ePCI. Predictive performance was evaluated using receiver operating characteristic curves, and restricted cubic splines were used to assess potential nonlinearity.

Results: From a cohort of 3,968 consecutive patients with spontaneous ICH from May 2015 to September 2022, 637 individuals (mean age 57.3 years [SD 12.5]; 71.3% male) were included in the final analysis, with 71 (11.1%) developing ePCI. The CCSE score showed excellent intrarater (κ = 0.93) and interrater (κ = 0.86) reliability and was strongly associated with ePCI risk (odds ratio 2.14 per point, 95% confidence interval [CI] 1.80-2.53, p < 0.001). Subgroup analyses confirmed the robustness of the association. The CCSE score outperformed traditional scores, including the Glasgow Coma Scale, Original Intracerebral Hemorrhage Scale, and Modified Intracerebral Hemorrhage A score (area under the curve = 0.91; 95% CI 0.86-0.95). Additionally, a nonlinear relationship was identified (p for nonlinearity = 0.002), with a CCSE score threshold ≥ 4.02 for risk discrimination.

Conclusions: The CCSE score may be a reliable and practical tool for predicting ePCI in patients with supratentorial ICH.

Background: Compared to in-hospital ischemic stroke, the prognosis of in-hospital intracranial hemorrhage (IH-ICH) remains poorly understood. We aimed to analyze the risk factors for early poor outcomes and propose a novel predictive nomogram for in-hospital ICH.

Methods: We retrospectively analyzed data of patients with in-hospital ICH treated in our hospital between 2014 and 2022. Baseline demographics, comorbidities, clinical characteristics, and outcomes were collected. The early poor outcome was defined as in-hospital death or discharge against medical advice. Univariate and multivariate logistic regressions were used to identify the risk factors and then construct a nomogram. The nomogram was compared with the ICH score in terms of predictive ability.

Results: A total of 196 patients were included; the median age was 57.0 (interquartile range 40.0-67.0) years, and 84 (49.7%) patients were male. Among the cohort, 135 patients had intraparenchymal hemorrhage, 27 had subarachnoid hemorrhage, 1 had intraventricular hemorrhage, 5 had subdural hemorrhage, and 1 had epidural hemorrhage. Overall, 96 (56.8%) patients developed an early poor outcome. Multivariate logistic regression identified prior spontaneous extracranial hemorrhage (ECH), baseline modified Rankin Scale (mRS) score ≥ 4, baseline Glasgow Coma Scale (GCS) score ≤ 8, and systemic disease etiology as independent risk factors for early poor outcomes. The IH-ICH nomogram, developed based on these risk factors, had good calibration and superior predictive performance compared to the conventional ICH score (area under the receiver operating characteristic curve 0.894 vs. 0.743, p < 0.001). Besides, the decision curve analysis curves revealed greater positive net benefit of the model than the ICH score.

Conclusions: Patients with prior ECH, severe coma (GCS score ≤ 8), poor functional status (mRS score ≥ 4), and systemic disease etiology face a significant risk of early poor outcomes. The IH-ICH nomogram incorporating these factors offers a promising tool for identifying high-risk patients with in-hospital ICH, thereby contributing to improved patient care and resource allocation in neurology and critical care settings.

Background: The prediction of delayed cerebral ischemia (DCI) and poor clinical outcome following aneurysmal subarachnoid hemorrhage (aSAH) is an unmet clinical need to improve on stratification of patients. DCI and poor clinical outcome following aSAH have been associated with hypercoagulability as detected by viscoelastic testing. This study assesses temporal alterations in rotational thromboelastography (ROTEM) coagulation profiles and the discriminative ability of ROTEM parameters for DCI and poor clinical outcome following aSAH.

Methods: ROTEM parameters were measured on admission, days 3-5, and days 9-11 after aSAH and compared between patients with and without DCI, radiological DCI, and poor 6-month clinical outcome as per modified Rankin Scale scores 4-6. Receiver operating characteristic curve analyses were used to calculate areas under the curve (AUCs) and determine cutoff values with a sensitivity > 90% for (radiological) DCI and with a specificity > 90% for poor outcome.

Results: Of 160 included patients with aSAH, 31 (19%) had DCI, 16 (10%) had radiological DCI, and 68 (44%) had poor outcome at 6 months. DCI, radiological DCI, and poor clinical outcome were associated with hypercoagulability. The ROTEM parameter with the best discriminative ability for radiological DCI was INTEM clotting time (AUC 0.75) on admission day, with an optimal cutoff value of < 146 s (sensitivity 92%, specificity 47%). For poor outcome, this was increased clot strength by FIBTEM amplitude at 10 minutes (A10, AUC 0.85) on days 3-5, with an optimal cutoff value > 27 mm (specificity 94%, sensitivity 49%).

Conclusions: In this study, ROTEM parameters indicative of increased coagulation had good predictive ability for poor clinical outcome. If independently validated, ROTEM parameters might have the potential to stratify patients with aSAH who may benefit from anticoagulant treatment in future trials with the aim to improve clinical outcome.