Neurocritical Care最新文献

Background: There have been growing sentiments that the Uniform Determination of Death Act needs to be revised. One suggestion is to include a conscience clause, that is, allowing patients to "opt-out" of brain death determination. Understanding public attitudes toward a conscience clause may help inform policymakers and future proposed revisions. Therefore, we sought to investigate informed public attitudes toward continued medical support after the determination of brain death.

Methods: A nationwide online survey was distributed by a third-party provider. The survey had three components: (1) a 2-min educational video that explains five basic facts of brain death, (2) a validated five-item questionnaire to measure understanding of brain death, and (3) a six-item questionnaire to measure informed public attitudes toward a family's request to continue medical support for a patient with brain death. Attitudes were measured on a seven-point Likert scale. A multiple linear regression model was developed to identify predictors of attitudes toward opting out of brain death. Analysis of variance with a post hoc Tukey test was used to compare attitudes across categorical demographic variables.

Results: We collected 1386 responses from participants across 49 states. The average five-item knowledge score was 88%. A total of 41.9% of all participants agreed that the hospital should be required to continue treatment for an individual with brain death if their family rejects brain death. A total of 24.4% and 27.3% of participants would request further treatment for themselves and a family member after a determination of brain death, respectively. Multiple linear regression identified attitudes for oneself and for a family member, age greater than 65 years, understanding that brain death is legal death, and male sex as predictors of attitudes toward requiring continued treatment (F(6, 1380) = 142.74, adjust R² = 0.38, p < 0.001).

Conclusions: Nearly half of the participants would require hospitals to continue treatment for families who reject brain death as death. Future discussions on revising the Uniform Determination of Death Act to adopt a conscience clause should consider informed public attitudes.

Traumatic brain injury (TBI) is a major cause of health loss and disabilities globally, burdening health care systems. Mild TBI is a common cause of emergency department visits. Computed tomography (CT) scans are the mainstay for acute TBI imaging. S100 calcium-binding protein B (S100B) biomarker is promising for predicting intracranial lesions on CTs in mild TBI. A comprehensive search of the literature was conducted on PubMed, Google Scholar, and Cochrane electronic databases to find eligible studies reporting the diagnostic performance of S100B. A meta-analysis was conducted to evaluate the predictive ability of S100B for CT imaging abnormalities. Of 1545 articles, 32 were included in our meta-analysis. At the threshold of 0.1 μg/L, a bivariate model showed a sensitivity of 89% (95% confidence interval [CI] 83-92) with a specificity of 32% (95% CI 26-39). The aggregate analysis containing all cutoffs showed the optimal cutoff of 0.751 μg/L with a sensitivity of 64% (95% CI 32-87) and a specificity of 85% (95% CI 76-92). The optimal diagnostic performance of S100B in patients with Glasgow Coma Scale 14-15 was estimated to be 0.05 μg/L, with a sensitivity of 98% (95% CI 92-99) and a negative predictive value of 99%. These findings indicate that S100B analysis could minimize the need for unnecessary CT scans in individuals with mild TBI. The test's diagnostic accuracy improves when the S100B analysis is done within 3 h of the injury. However, further research is warranted to validate its superiority to other biomarkers before considering it the standard routine for managing mild TBI.

Background: Our objective was to characterize the impact of common initial sedation practices on invasive mechanical ventilation (IMV) duration and in-hospital outcomes in patients with acute brain injury (ABI) and to elucidate variations in practices between high-income and middle-income countries.

Methods: This was a post hoc analysis of a prospective observational data registry of neurocritically ill patients requiring IMV. The setting included 73 intensive care units (ICUs) in 18 countries, with a total of 1,450 patients with ABI requiring IMV. There were no interventions.

Results: Patients were categorized into day 1 propofol, midazolam, propofol and midazolam, dexmedetomidine, or sodium thiopental. The primary outcome was duration of IMV. Secondary outcomes were ICU and hospital mortality, ICU length of stay, days to first extubation, extubation failure, and withdrawal of life-sustaining therapy. Multivariable analyses were adjusted for clinically preselected covariates. Of 1,450 included patients (median age 54 years, 66% male), 41.2% (n = 597) were started on propofol, 26.1% (n = 379) were started on midazolam, 19.9% were started on propofol and midazolam, 0.3% (n = 5) were started on sodium thiopental, 0.7% (n = 10) were started on dexmedetomidine, and 11.8% (n = 171) were treated without sedation. After adjustment, there was no significant difference in IMV duration between patients who received midazolam (aβ = 0.64, p = 0.43, 95% confidence interval [CI] - 0.96 to 2.24) or propofol and midazolam (aβ = 0.32, p = 0.46, 95% CI - 1.44 to 2.12) compared with patients who received propofol. Patients who were started on midazolam had an average length of ICU stay that was 2.78 days longer than patients started on propofol (p = 0.003, 95% CI 0.94-4.63). There were no differences in mortality, days to first extubation, extubation failure, or withdrawal of life-sustaining therapy. Patients from high-income countries (n = 1,125) were more likely to receive propofol on day 1 (45.7 vs. 25.5%), whereas patients from middle-income countries (n = 325) were more likely to receive midazolam (32.6 vs. 24.3%) (p < 0.001).

Conclusions: In an international registry of patients with ABI requiring IMV, IMV duration did not differ significantly relative to initial sedation strategy. However, patients started on midazolam had longer ICU stay.

Background: Neuroleptic malignant syndrome (NMS) is a psychiatric-neurologic emergency that may require intensive care management. There is a paucity of information about NMS as a critical illness. We reviewed the Mayo Clinic experience.

Methods: A comprehensive data extraction was completed within the Mayo Clinic system diagnosed with NMS using International Classification of Diseases, ninth revision (ICD-9); ICD-9, Clinical Modification; ICD-10; ICD-10, Clinical Modification; and Health Insurance Claim (HIC) codes between the years of 1995 and 2023. Major criteria included fever, rigidity, tachycardia, and exposure to a neuroleptic agent. Minor criteria included rhabdomyolysis and dysautonomia. Criteria for exclusion were Parkinson's disease, abrupt discontinuation of baclofen or levodopa, concomitant selective serotonin reuptake inhibitors use or serotonin syndrome, malignant catatonia, or a classic dystonic reaction.

Results: A total of 332 patients had diagnostic codes of NMS, but only 20 patients fulfilled DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision), diagnostic criteria. The average age was 48.2 years (range 20-93 years). Four patients received antipsychotics following postoperative acute agitation or delirium (20%). Previous psychiatric diagnoses were schizophrenia or schizoaffective disorder in six patients (33%), major depressive disorder in five patients (20%), and bipolar disorder in two patients (10%). Haloperidol was the sole inciting neuroleptic in five patients (25%), but the remainder was associated with atypical or second-generation antipsychotics. A total of nine patients (45%) required mechanical ventilation. The majority of patients had rhabdomyolysis, which led to acute kidney failure in nearly half of them, but none required hemodialysis. Most patients recovered promptly, and no fatalities were directly attributable to NMS; however, four patients (20%) died within 1 month, and four patients died years from diagnosis and unrelated to NMS.

Conclusions: Neuroleptic malignant syndrome can become a critical illness, but there is often rapid recovery. Mortality proximate to NMS was uncommon, but late mortality remained substantial. The overwhelming majority of cases coded as NMS did not meet DSM-5 diagnostic criteria. Stricter criteria should be applied when diagnosing NMS in critical care and emergency medicine settings.

Background: Controlled donation after circulatory determination of death (DCD) is feasible only if circulatory arrest occurs soon after withdrawal of life-sustaining measures (WLSM). When organ recovery cannot proceed because this time interval is too long, there are potential negative implications, including perceptions of "secondary loss" for patients' families and significant resource consumption. The DCD-N score is a validated clinical tool for predicting rapid death following WLSM. We hypothesized that neuroimaging evidence of effaced perimesencephalic cisterns improves prediction of time to death compared with the DCD-N score alone.

Methods: In a retrospective population-based cohort study, DCD-N scores were prospectively determined in patients for whom consent for DCD had been obtained. Perimesencephalic cisterns on last available neuroimaging were assessed in duplicate and classified as normal, partially effaced, or completely effaced. Multivariable logistic regression assessed the capacity of DCD-N score and effaced cisterns to predict death within 1, 2, or 3 h of WLSM.

Results: Of 164 consecutive patients, 49 (30%) progressed to death by neurologic criteria and were excluded. Of the remaining 115 patients, 81 (70%) died within 2 h of WLSM. When perimesencephalic cisterns were patent, this occurred in 48% of patients, compared with 88% and 93%, respectively, of patients with partially and completely effaced cisterns (p < 0.0001). In multivariable analysis, the odds ratio for prediction of death within 2 h was 7.2 (2.8-18.3) for each incremental DCD-N score and 15.4 (4.1-58.1) for the presence of either partially or completely effaced cisterns (c = 0.92 vs. 0.75-0.84 for univariate models). Results were comparable for prediction of death within 1 or 3 h. With patent cisterns, median time to death was 132.5 (21-420) minutes, compared with 23.5 (16-32) and 22 (19-30) minutes, respectively, with partially and completely effaced cisterns (p = 0.0002).

Conclusions: Cerebral edema with effaced perimesencephalic cisterns predicts rapid death following WLSM in potential DCD organ donors and improves on performance of the DCD-N score alone. Although originally validated for the prediction of death within 1 h, the DCD-N score remains predictive up to 3 h following WLSM.

Background: Neurovascular coupling (NVC) refers to the process of aligning cerebral blood flow with neuronal metabolic demand. This study explores the potential of contralateral NVC-linking neural electrical activity on the stroke side with cerebral blood flow velocity (CBFV) on the contralesional side-as a marker of physiological function of the brain. Our aim was to examine the association between contralateral NVC and neurological outcomes in patients with ischemic stroke following endovascular thrombectomy.

Methods: We concurrently recorded the CBFVs of the middle cerebral arteries and electroencephalographic (EEG) signals of patients after endovascular thrombectomy. We employed phase-amplitude cross-frequency coupling to quantify the contralateral coupling between EEG activity on the stroke side and CBFV on the contralesional side. Key neurological outcomes were measured, including changes in National Institute of Health Stroke Scale (NIHSS) scores, infarct volume progression over 7 days, and modified Rankin Scale scores at 90 days.

Results: A total of 52 study participants were enrolled in our study (mean age 61.5 ± 10.4 years; 90.4% male; median preprocedural NIHSS score 14 [interquartile range 10-17]). We successfully computed contralateral NVC in 48 study participants. A significant association emerged between contralateral coupling and improvements in NIHSS scores over 7 days (theta band, P = 0.030) and in infarct volume progression (delta band, P = 0.001; theta band, P = 0.013). Stronger contralateral NVC in the delta and theta bands correlated with better outcomes at 90 days (adjusted odds ratio for delta 7.53 [95% confidence interval 1.13-50.30], P = 0.037; adjusted odds ratio for theta 6.36 [95% confidence interval 1.09-37.01], P = 0.039).

Conclusions: A better contralateral coupling between stroke-side EEG and contralesional CBFV is associated with favorable neurological outcomes, suggesting that contralateral NVC analysis may aid in assessing brain function after recanalization. Replication with a deeper understanding of the mechanisms is needed before clinical translation.

Background: Optic nerve sheath diameter (ONSD) is a promising noninvasive parameter for intracranial pressure (ICP) assessment. However, in the setting of aneurysmal subarachnoid hemorrhage (aSAH), several previous studies have reported no association between ultrasonically measured ONSD and ICP. In this study, we evaluate ONSD in patients with aSAH using a novel method of automated real-time ultrasonographic measurements and explore whether factors such as having undergone surgery affects its association to ICP.

Methods: We prospectively included adult patients with aSAH undergoing invasive ICP monitoring. ONSD was obtained using a prototype ultrasound machine with software for real-time automated measurements at the bedside. Correlation between ONSD and ICP was explored, and the ability of ONSD to discriminate dichotomized ICP was evaluated. Abovementioned analyses were performed for the whole cohort and repeated for subgroups by whether the basal cisterns had been surgically entered before ultrasound examination.

Results: Twenty-six ultrasound examinations were performed in 20 patients. There was a positive correlation between ONSD and ICP (R = 0.43; p = 0.03). In the subgroup where the basal cisterns had not been surgically entered before ultrasound examination, there was a stronger correlation (R = 0.55; p = 0.01), whereas no correlation was seen in the subgroup where the basal cisterns had been surgically entered (R = - 0.16; p = 0.70). ONSD displayed an ability to discriminate ICP dichotomized at ≥ 15 mm Hg (area under the curve [AUC] = 0.84, 95% confidence interval [CI] 0.65-0.96). Subgroup analysis revealed a perfect discriminatory ability (AUC = 1, 95% CI 0.81-1) where the basal cisterns had not been surgically entered and no discriminatory ability (AUC = 0.47, 95% CI 0.16-0.84) where the basal cisterns had been surgically entered before ultrasound examination.

Conclusions: Automatically measured ONSD correlated well with ICP and displayed a perfect discriminatory ability in patients with aSAH in whom the basal cisterns had not been entered surgically before ultrasound examination, and may be a clinically valuable noninvasive marker of ICP in these patients. Caution should be exercised in using ONSD in patients in whom the basal cisterns have been entered surgically before ONSD measurements, as no association was observed in this subgroup.

Background: Invasive mechanical ventilation can present complex challenges for patients with acute brain injury (ABI) in middle-income countries (MICs). We characterized the impact of country income level on weaning strategies and outcomes in patients with ABI.

Methods: A secondary analysis was performed on a registry of critically ill patients with ABI admitted to 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Patients were classified as high-income country (HIC) or MIC. The primary outcome was ICU mortality. Secondary outcomes were days to first extubation, tracheostomy, extubation failure, ICU length of stay, and hospital mortality. Multivariable analyses were adjusted for clinically preselected covariates such as age, sex, body mass index, neurological severity, comorbidities, and ICU management. Extubation and tracheostomy outcomes were also adjusted for arterial blood gas values and ventilatory settings.

Results: Of 1512 patients (median age = 54 years, 66% male), 1170 (77%) were from HICs, and 342 (23%) were from MICs. Median age was significantly lower in MICs [35 (range 26-52) vs. 58 (range 45-68) years in HICs]. Neurosurgical procedures (47.7% vs. 38.2%) and decompressive craniectomy (30.7% vs. 15.9%) were more common in MICs, whereas intracranial pressure monitoring (12.0% vs. 51.5%) and external ventricular drain (7.6% vs. 35.6%) were less common. Compared with HICs, patients from MICs had 2.27 times the odds of ICU mortality [p = 0.009, 95% confidence interval (CI) 1.22-4.21]. Frequency of extubation failure was lower in MICs but not significant after adjustment. Patients from MICs had 3.38 times the odds of tracheostomy (p ≤ 0.001, 95% CI 2.28-5.01), 5.59 days shorter mean ICU stay (p < 0.001, 95% CI - 7.82 to - 3.36), and 1.96 times the odds of hospital mortality (p = 0.011, 95% CI 1.17-3.30).

Conclusions: In an international registry of patients with ABI requiring invasive mechanical ventilation, MICs had higher odds of ICU mortality, tracheostomy placement, and hospital mortality compared with HICs, which may be due to difference in neurocritical care resources and management.

Background: Microcirculatory dysfunction is one of the most important pathophysiology mechanisms of global cerebral edema (GCE) after aneurysmal subarachnoid hemorrhage (aSAH). Data regarding the impact of microcirculatory dysfunction on persistent GCE following aSAH are currently lacking. The aim of our study was to investigate whether microcirculatory dysfunction is correlated with persistent GCE in patients with aSAH across different age groups.

Methods: The study was conducted in Beijing Tiantan Hospital from October 2020 to July 2023. Patients with aSAH who underwent computed tomographic perfusion (CTP) within 24 h after ictus were enrolled prospectively. The difference value of arteriovenous peak time (DV), which serves as an indicator of microcirculatory impairment, was derived from the time-density curve of CTP. Persistent GCE was defined as selective sulcal volume ≤ 11.3 mL at both admission and 7 ± 1 days after ictus. Age-stratified multivariable analyses were applied to identify the association between microcirculatory dysfunction and persistent GCE.

Results: A total of 390 patients with aSAH were enrolled; the mean age was 56.5 ± 12.1 years old, and 245 (65.1%) patients were female. On multivariable analysis, prolonged DV was significantly associated with increased risk of persistent GCE after aSAH in patients older than 60 years (adjusted odds ratio 1.350, 95% confidence interval 1.025-1.778), whereas this similar independent association was not observed in patients younger than 60 years after adjusting for confounding factors (adjusted odds ratio 1.002, 95% confidence interval 0.817-1.229).

Conclusions: An age-dependent association between microcirculatory dysfunction and increased risk of persistent GCE following aSAH was found, which offers promising insight into future research to investigate tailored treatments across different ages.

Background: Socioeconomic status affects outcomes in cerebrovascular disease, although its role in the withdrawal of life-sustaining treatments (WLST) remains uncertain. We aim to examine the impact of socioeconomic factors on outcomes including WLST in aneurysmal subarachnoid hemorrhage (aSAH).

Methods: We conducted a retrospective study of a cohort of consecutive patients with aSAH who were admitted to an academic center from 2016 to 2023. Publicly available data on median neighborhood income by zip code areas were obtained from the US census. Low economic-insurance status (EIS) was defined as using Medicaid or having no insurance or living in a zip code within the lowest two quintiles of household income. High EIS was defined as not using Medicaid and having any other insurance and living in a zip code within the highest two quintiles of household income. The rest of the cohort who was not categorized in the high or low EIS groups was defined as middle EIS. We used multivariable logistic regression analysis to assess the association between socioeconomic and demographic factors and outcomes including WLST, mortality, and 3-month modified Rankin Scale.

Results: We included 410 patients, with mean age 57.9 years (standard deviation 13.8), who were 65% female, 70% white, 36.8% low EIS, and 35.6% high EIS. Higher EIS was associated with WLST (odds ratio 1.53 per increase in EIS, 95% confidence interval 1.07-2.18; p = 0.02) when adjusted for other predictors. In addition, a higher quintile of neighborhood income, regardless of insurance status, was associated with higher odds of WLST (odds ratio 1.41 per each quintile increase, 95% confidence interval 1.07-1.86; p = 0.014). However, there was no association between EIS and 3-month modified Rankin Scale when adjusted for disease severity factors.

Conclusions: Higher EIS and residing in areas with higher neighborhood incomes were associated with higher odds of WLST in aSAH. Further multicenter studies are needed to investigate the underlying mechanisms that contribute to these associations.