Neurocritical Care最新文献

Introduction: There has been a surge in attention to ethical controversies associated with organ donation in the USA. The Neurocritical Care Society (NCS) Ethics Committee sought to understand member experiences and attitudes related to organ donation in the USA.

Methods: We designed a survey of members who practice in the USA and have interacted with an organ procurement organization (OPO)/potential donor. The survey was disseminated by NCS from 1 June 2025 to 1 September 2025. Free-text responses were reviewed to identify themes.

Results: Of 2204 NCS members in the USA, there were 71 respondents who completed the survey and 37 respondents who provided free-text comments. Experiences and attitudes varied, but 59% of respondents indicated that they generally think that communication between the OPO and patient surrogates about donation after brain death/death by neurologic criteria seems appropriate, and 34% indicated that they generally think that communication between the OPO and patient surrogates regarding donation after cardiac death/death by circulatory-respiratory criteria (DCD) seems appropriate. Themes included (1) the need to improve education for the treatment team about organ donation; (2) blurred boundaries between patient care and care directed toward organ donation; (3) misalignment between OPOs and treatment team priorities; (4) loss of trust between patient surrogates and the treatment team based on interactions with OPOs; (5) suboptimal timing of communication between OPOs and patient surrogates; (6) concerns regarding a potential lack of transparency, empathy, and cultural sensitivity in communication between OPOs and patient surrogates; (7) opportunities for improvement in preoperative care before donation and palliation after extubation for DCD; and (8) changes in willingness to donate organs based on interactions with OPOs.

Conclusions: Although the results from this survey reflect the experience and attitudes of a small percentage of NCS members in the USA, they indicate that there are opportunities for improvement in organ donation processes. Survey results will guide the NCS Ethics Committee in supporting members navigating ethical controversies related to organ donation.

Background: Cognitive morbidities persist after pediatric critical care. However, a significant gap exists related to measuring cognitive outcomes in this patient population due to heterogeneity in presentations and objective measures. This study's purpose was to develop a psychometrically sound coding system to summarize clinically generated and performance-based neuropsychological outcomes to be used for research.

Methods: The work was conducted in two stages: (1) Cognitive Status Scale (CSS) development and (2) a retrospective pilot test in a clinically referred sample of post-critical-care youth aged 6-19 years (N = 110) to explore preliminary psychometric properties of the CSS.

Results: Principal components analysis supported the CSS structure (capturing 59% of the total explained variance). Internal consistency (α = 0.82) and interrater reliability (r = 0.92) were good. Within the full sample, criterion-related validity was demonstrated as the CSS total composite score from long-term evaluation and was significantly correlated with abbreviated performance-based cognitive outcomes from the acute recovery phase (Neurocognitive Index, r = 0.74). Divergent validity was shown via significant differences on the CSS total composite score between known clinical groups (≥ 3 Functional Status Scale [FFS] change = 30.23 vs. ≤ 2 FFS change = 50.94, t = 4.10, p ≤ 0.001, d = 0.91) and across CSS clinical indicators (F_3,106 = 8.4495, p =  < 0.001, η² = 0.194). Bivariate correlations showed a significant association in the expected direction between the CSS total composite score and the Functional Status Scale total score (r =  - 0.44, p ≤ 0.001), as well as a significant association in the expected direction between the CSS total composite score and the Behavior Rating Inventory of Executive Function, Second Edition General Executive Composite (r =  - 0.29, p = 0.010).

Conclusions: Primary evidence shows the CSS to be a reliable and valid measure for summarizing a clinically administered battery of cognitive assessments. Easy-to-generate metrics of performance-based cognition are essential to progress the state of the science germane to cognitive outcomes post pediatric critical care.

Background: Low-field portable magnetic resonance imaging (pMRI) systems have been approved for clinical use, but their feasibility, efficacy, and most appropriate clinical application in children are unknown. The objective of this study was to evaluate the diagnostic accuracy of pMRI in detecting acute brain injury (ABI) in critically ill children compared to conventional MRI (cMRI) and or computed tomography (CT).

Methods: This prospective diagnostic accuracy study included children (1 month to < 18 years) admitted between May 2021 and June 2022 who underwent pMRI scans within a 24-h window of standard neuroimaging (CT or cMRI). pMRI images were assessed for quality of images and interpreted for findings by two independent pediatric radiologists blinded to the findings of the standard imaging modalities. Diagnostic accuracy was assessed using sensitivity, specificity, and agreement statistics.

Results: pMRI scans were successfully completed in 83% of the cases (73 of 88 patients) with a median scan time of 48 min (interquartile range 43-54 min), with no patient- or machine-related adverse event. Neuroimaging indications were seizures in 38 (52.1%), unexplained encephalopathy in 29 (39.7%), and focal neurologic deficits in 19 (26%) patients. Radiological findings of pMRI included edema in 28 (38.4%), hydrocephalus in 12 (16.4%), infarction in 13 (17.8%), midline shift in 12 (16.4%), and intraparenchymal hemorrhage in 7 (9.6%). The pMRI demonstrated good agreement with cMRI and CT scans for detecting edema (87% agreement, κ = 0.7), hydrocephalus (94% agreement, κ = 0.8) and intraparenchymal hemorrhage (87% agreement, κ = 0.6). Compared to cMRI, pMRI showed 72% agreement (κ = 0.41, P = 0.0002), with 98% specificity and 73% sensitivity for hydrocephalus. Overall agreement between the two observers for pMRI was 90% (κ = 0.81, P < 0.001). Image quality was adequate for T1-weighted (n = 58, 79.5%), T2-weighted (n = 61, 83.6%), diffusion-weighted imaging (DWI) (n = 49, 67.1%), and apparent diffusion coefficient (n = 48, 65.8%) sequences. The highest number of uninterpretable images were for the DWI sequence (n = 9, 12.3%).

Conclusions: pMRI is a safe and feasible bedside imaging modality that shows promising results in diagnosing ABI in children.

Background: Minimally invasive surgery (MIS) for large supratentorial intracerebral hemorrhage (ICH) addresses primary brain injury by reducing mass effect, causing midline shift (MLS). We investigated the relationship between MIS, MLS, and functional outcomes in a large clinical trial.

Methods: We conducted a post hoc analysis of patients with qualified computed tomography (CT) images from the phase 3 Minimally Invasive Surgery Plus Alteplase for Intracerebral Haemorrhage Evacuation trial. The exposure was MLS at the pineal gland (PG) and septum pellucidum (SP) on CT scans at diagnosis, end of treatment (EOT), and hospital discharge. The primary outcome was 30-day mortality. Secondary outcomes were mortality and modified Rankin scale score at day 365. We performed multivariable logistic regression and mediation analyses, adjusted for demographics, ICH characteristics, and treatment.

Results: Participants had a median age of 62 years and a median ICH volume of 44 mL, and 61% were male. Thirty-day mortality was 12%. MLS on EOT CT was significantly lower in surgical patients compared with medical patients. EOT MLS in day 30 surgical survivors was also significantly lower compared with that in medically treated survivors and nonsurvivors. The odds of 30-day mortality on adjusted analyses were significantly increased by 1 mm in MLS at both the PG and SP (PG: odds ratio 1.22, 95% confidence interval 1.06-1.41; SP: odds ratio 1.22, 95% confidence interval 1.10-1.36). Thresholds of MLS change < 3 mm (SP) and < 5 mm (PG) were associated with mortality reduction. The association of MIS with 30-day mortality was mediated fully by change in either the SP or PG MLS from diagnostic to EOT CT. Change in MLS was significantly associated with one-year mortality and, for SP, with one-year good functional outcome (modified Rankin scale scores 0-3).

Conclusions: MIS for ICH significantly reduces MLS. This reduction in MLS significantly mediates reduction in 30-day mortality with MIS and is associated with both short-term and long-term outcomes.

Background: Septic shock is a recognized cause of global mortality in intensive care units. Sedation and analgesia management are essential for patients with sepsis or hemodynamic instability. Although considered safe concerning hemodynamic changes, ketamine use might cause a substantial rise in intracranial pressure (ICP).

Methods: An interventional study was conducted at the intensive care unit of Zagazig University Hospitals from December 2021 to March 2023 and covered 100 adult patients with septic shock requiring mechanical ventilation, sedation, and vasopressors. Patients with acute brain injury were excluded. Noninvasive ICP including ICP derived from pulsatility index, ICP derived from diastolic flow velocity (ICP_FVd), and ICP derived from optic nerve sheath diameter, and hemodynamic monitoring were measured before adjunct low-dosage (0.3 mg/kg/hr) continuous ketamine infusion (T0), after 12 h (T1), and after 24 h of infusion (T2).

Results: Baseline ICP derived from optic nerve sheath diameter, ICP derived from pulsatility index, and ICP_FVd medians were 14.5 (interquartile range [IQR] 7), 16.8 (IQR 0.91), and 13.8 (IQR 9.38) mm Hg, respectively. Only ICP_FVd showed a significant slight increase from 13.75 (IQR 8.5) at T1 to 13.90 (IQR 8.5) at T2 (P value = 0.042). The baseline median noninvasive cerebral perfusion pressure was 74.56 (IQR 12.39) mm Hg without significant change at T1 or T2 (P value = 0.09). The respiratory rate, heart rate, and mean arterial blood pressure showed no significant changes across timepoints (P values = 0.95, 0.86, and 0.14, respectively). The median doses of midazolam, fentanyl, and norepinephrine significantly decreased across the study timepoints, especially at the first 12 h (P value < 0.001 for each).

Conclusions: The present pilot study showed promising results of low-dose continuous ketamine infusion adjunctly on ICP and hemodynamics with a substantial reduction of sedatives and vasopressor dose. Further studies with large sample sizes and longer duration of administration and follow-up are needed to expand the current findings.

Background: Detecting covert consciousness in unresponsive patients is challenging. Although functional magnetic resonance imaging and advanced electroencephalography paradigms can identify volitional brain activity, the limited accessibility of these technologies necessitates alternative approaches. Functional near-infrared spectroscopy may provide a portable solution in the intensive care unit. We assessed the feasibility of functional near-infrared spectroscopy with verbal motor commands to detect volitional brain activity in acute disorders of consciousness (DoC).

Methods: Functional near-infrared spectroscopy recordings and clinical assessments were obtained from 50 patients with DoC with acute brain injury, with data analyzed post hoc and visually at the bedside. Twenty healthy volunteers served as controls.

Results: After quality control, data from 19 controls and 36 patients were analyzed. Cortical activation was detected in 18 (96%) controls and 16 (44%) patients. Among 13 minimally conscious patients, volitional activity was found in 8 (62%), whereas 8 (35%) of 23 clinically unresponsive patients showed activation. Volitional brain activity in the latter was associated with higher odds of command following within a week, although it was not statistically significant (odds ratio 3.1, 95% confidence interval 0.7-15.8; p = 0.14). Visual bedside analysis showed high specificity (90%) but moderate agreement (κ = 0.4) with post hoc computational analysis.

Conclusions: Functional near-infrared spectroscopy with motor commands can detect volitional brain activity in acute DoC, although data quality issues remain a limitation.

We present the case of a 69-year-old woman with acute myeloid leukemia with recurrent transient events characterized by loss of awareness and generalized shaking. The events were initially diagnosed as seizures based on semiology but persisted despite antiseizure medications. The events were recorded using continuous video electroencephalography (EEG) with no epileptiform correlate. However, pertinent changes included diffuse attenuation of fast activity, increase in delta activity, and subsequent attenuation of faster frequencies. Quantitative EEG detected a decrease in fast activity, alpha-delta ratio, and amplitude-integrated EEG. The transient events and EEG findings in the setting of known cancer history raised concern for carcinomatous meningitis despite unremarkable brain imaging. Lumbar puncture showed an elevated opening pressure and cytology confirmed a myeloid blast population consistent with acute myeloid leukemia. The events resolved with serial lumbar punctures supporting the fact that the events were likely secondary to transient elevations in intracerebral pressure. In summary, video EEG with quantitative EEG analysis is a sensitive, non-invasive way to confirm transient elevated intracranial pressure and rule out epileptic activity. This constellation of cancer, clinical symptoms and EEG findings should increase suspicion of carcinomatous meningitis.