Neurocritical Care最新文献

Background: In neurocritical care units (NCCU), decisions to withhold life-sustaining therapies are sometimes influenced by anticipated disability and quality of life (QoL) impairment, particularly when further interventions are deemed futile. However, health-related QoL (HRQoL) is inherently subjective and does not always correlate with disability levels. This qualitative, noninterventional study aimed to assess the relevance of HRQoL in ethical decision-making using interpretative phenomenological analysis (IPA) to investigate subjective HRQoL.

Methods: Patients were interviewed by a single intensivist to assess their subjective QoL 2 years after their stay in an NCCU following an acute brain injury (ABI). The intensivist directed the interview toward HRQoL using a guide comprising limited and mostly open-ended questions. Audio recordings of the interviews were transcribed verbatim into Word narratives, analyzed in depth by two intensivists using IPA methodology and NVivo 14 software to enable exploration of patients' lived experiences and personal QoL assessments.

Results: A total of 14 patients were invited to the follow-up appointment, 7 for whom life-sustaining treatment had been withheld in the NCCU and 7 matched patients for whom this decision had not been made. Among the nine patients finally included, life-sustaining treatment had been withheld in four cases. Patients varied greatly in how they perceived and valued their QoL. While most valued relationships and independence, they expressed these values in different ways. Frustration with disability and support from relatives emerged as key motivators for rehabilitation. Despite their challenges, patients expressed gratitude for survival and pride in their progress and daily achievements. Overall, their experiences highlighted the deeply personal and subjective nature of disability and QoL assessment.

Conclusions: HRQoL after ABI is highly subjective and should be considered with great caution in decisions to withhold life-sustaining treatment in NCCU. Further studies are warranted to improve outcome assessment after ABI and aid ethical decision-making.

Objective: With the introduction of andexanet alfa, a specific antidote is now available to address life-threatening bleeding associated with factor Xa inhibitors. In this study, we explore its use in an experimental model of traumatic brain injury (TBI), mimicking a closed head trauma under rivaroxaban-induced anticoagulation.

Methods: Male C57BL6 mice were fed with rivaroxaban (10 mg/kg body weight). Subsequently, TBI was induced by controlled cortical impact (CCI) and andexanet alfa or placebo were administered as intravenous bolus injections. Edema and hemorrhage volume was quantified by magnetic resonance imaging (MRI) 24 h and 7 days after CCI. Functional outcome was assessed at day 1, 3, and 7 thereafter.

Results: Andexanet alfa led to reduced hemorrhage volume 24 h and 7 days after CCI as compared with control group without reversal of anticoagulation (2.9 ± 1.4 µl vs. 5.2 ± 3.3 µl, p = 0.02; 3.4 µl ± 1.5 µl vs. 5.5 µl ± 2.4 µl, p = 0.04). Along with the smaller hematoma sizes in the MRI, edema volume was significantly lower in mice treated with andexanet alfa 24 h and 7 days after CCI (-6.3% of contralateral hemisphere, p = 0.0002; and -7.1% of contralateral hemisphere, p = 0.006). While functional outcomes did not differ at 24 h following TBI, andexanet alfa improved neurological deficits after 7 days.

Conclusions: Our experimental data suggests that the use of andexanet alfa improves functional outcomes by reduction of factor Xa inhibitor-associated hematoma expansion in the subacute phase following TBI.

Background: Low sociodemographic index (SDI) countries bear a disproportionate burden of aneurysmal subarachnoid hemorrhage (SAH) yet remain underrepresented in medical research.

Methods: A retrospective multicenter cohort of 1145 patients from tertiary centers in Brazil and the USA (2012-2024). Demographics, clinical severity (WFNS, modified Fisher scale, mFs), treatment modality, and outcomes were compared. Primary outcomes were in-hospital mortality and poor functional outcome (mRS > 2); secondary outcome was hospital length of stay (LOS). Multiple imputation was used for missing at random (MAR)-type missingness; adjusted models incorporated Bonferroni correction.

Results: Mean age was 54.5 ± 14.4 years; 73.9% female. Racial/ethnic distribution was 49.6% White, 23.5% Black, 19.5% multiracial, 1.7% Asian, 5.6% other, and 0.2% Native American. Hypertension and smoking were more prevalent among American patients, Black and White individuals, respectively. Brazilian patients underwent microsurgery more often (61.9% vs. 92% endovascular in the USA) and had markedly longer time to treatment (77.7 vs. 4.3 h; p < 0.0001). In-hospital mortality was higher in Brazil (23.4% vs. 13.4%; OR 1.98; p < 0.0001) and remained significant after adjustment. LOS was shorter in the USA (-5.4 days; p = 0.0021). Black Brazilians had worse outcomes (OR 2.3; p = 0.0028), while White patients trended toward lower mortality overall (OR 0.7; p = 0.0350). Rehabilitation access differed sharply (39.8% vs. 0.8%). Poor long-term outcome was more common in Brazil (53.2% vs. 38.8%; p < 0.0001).

Conclusions: Although USA patients had more vascular comorbidities, Brazilian hospitals experienced substantially higher mortality and long-term disability. These differences were consistent with disparities in care delivery and resource availability-reflected by longer treatment delays, differing treatment modalities, and limited access to post-acute rehabilitation-beyond measured patient-level risk, while also underscoring the importance of primary care-based prevention in high-income settings.

Background: This study evaluates the outcomes and management considerations associated with using extracorporeal membrane oxygenation (ECMO) in patients with traumatic brain injury (TBI), including those requiring neurosurgical intervention. It examines the feasibility of managing patients with TBI and neurosurgical patients on ECMO by synthesizing institutional data with the existing literature, emphasizing observed clinical contexts, anticoagulation strategies, and peri-procedural factors relevant to safe ECMO use. Our aim is to elucidate the potential for ECMO to be safely applied in patients with TBI needing intensive cardiopulmonary support, and for neurosurgical intervention to remain an option when indicated.

Methods: We retrospectively reviewed the medical records of seven patients with TBI who received ECMO therapy at our institution. The peri-ECMO period was defined as 7 days before ECMO cannulation to 7 days after decannulation. A systematic review of the literature was conducted to compare outcomes, complications, and management strategies.

Results: Most patients in our cohort were managed without systemic anticoagulation during ECMO treatment. Five patients underwent neurosurgical procedures in the peri-ECMO period with overall positive outcomes. In the systematic review, outcomes for patients with TBI receiving ECMO varied; while some demonstrated neurological improvement, others succumbed to complications such as septic shock and multiorgan failure. A subset of patients with TBI developed intracranial hemorrhage (ICH) while on ECMO, a concern that often discourages its use. They, along with other non-TBI patients who developed ICH while on ECMO, were subsequently treated with neurosurgical interventions with the majority showing functional improvement. Key factors affecting prognosis included ICH size, timing of neurosurgical intervention, and careful adjustment of anticoagulation therapy.

Conclusions: This study highlights that ECMO can be safely utilized in patients with TBI requiring intensive cardiopulmonary support, including those undergoing neurosurgical procedures for ECMO-related complications. In this high-risk population, maintaining ECMO circuits without systemic anticoagulation or with conservative anticoagulation should be considered. Our findings suggest that TBI should not be an absolute contraindication for ECMO therapy, and neurosurgical interventions can be safely performed in these patients, especially when ICH occurs.

Background: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality worldwide, often complicated by hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP). These infections may contribute to prolonged hospitalizations and increased morbidity. We conducted a systematic review and meta-analysis to identify predicting factors associated with the development of pneumonia (HAP or VAP) in patients hospitalized following acute TBI.

Methods: We conducted a comprehensive search of Medline and Embase from inception to 29 September 2025. We included studies that investigated prognostic factors for HAP or VAP in adult patients admitted to hospital with TBI and adjusted for known cofounders. We pooled adjusted odds ratios (aORs) using a random-effects model. We assessed risk of bias using the QUIPS tool and certainty of findings using GRADE methodology.

Results: We included 24 studies involving 34,841 patients. Prognostic factors with a moderate or high association of developing HAP or VAP include male sex (aOR 1.52, 95% CI 1.16-2.01; high certainty), lower Glasgow Coma Scale at any time (aOR 6.36, 95% CI 1.91-21.14; moderate certainty), chest injury severity (aOR 1.56, 95% CI 1.02-2.40; moderate certainty), barbiturate use (aOR 1.83, 95% CI 0.88-3.83; moderate certainty), and the need for invasive mechanical ventilation (aOR 6.22, 95% CI 4.05-9.55; moderate certainty). We also found that early antibiotic use (aOR 0.40, 95% CI 0.23-0.72; moderate certainty) is probably associated with a reduced incidence of pneumonia.

Conclusions: Pneumonia in patients with TBI is influenced by patient characteristics, injury severity, and treatment-related factors. Recognizing these risk factors may guide early interventions to reduce pneumonia and improve patient outcomes.

Background: Severe traumatic brain injury (sTBI) is a major cause of mortality and long-term disability, and early prognostic evaluation is essential to support therapeutic decision-making in intensive care. MRI is the reference imaging modality for detecting diffuse axonal injury (DAI), yet the prognostic accuracy and reproducibility of MRI-based radiologic scoring systems remain uncertain. This study aimed to compare the prognostic performance of five published MRI-based DAI scores for predicting 1-year neurological outcome, in a cohort of sTBI patients admitted to intensive care.

Methods: We analyzed adult patients with sTBI included in the prospective MRI-COMA cohort (NCT00577954). Inclusion criteria were age ≥ 18 years, admission to ICU for sTBI, and absence of command following within 7 days after sedation withdrawal. Brain MRI was performed between day 7 and day 35 post-injury using standardized T1, FLAIR, T2*/SWI, and diffusion-weighted sequences. Three blinded evaluators (one neurointensivist, two neuroradiologists) independently applied five radiologic scores (Adams, Firsching, Hamdeh, Stockholm, Trondheim). The primary endpoint was the ability of each MRI-based radiologic score to predict 1-year neurological outcome, dichotomized as favorable (GOSE 5-8) or unfavorable (GOSE 1-4). Inter-rater reliability was quantified using Cohen's and Fleiss' kappa coefficients.

Results: Between 2007 and 2023, 443 patients were screened and 185 met eligibility criteria. At one year, 111 patients (59%) had an unfavorable outcome. The prognostic performance of the five MRI scores was moderate, with AUCs ranging from 0.60 [CI95 0.52-0.68] to 0.70 [CI95 0.63-0.77], with no significant differences across scores or raters even between the intensivist and radiologists. Inter-rater reliability was fair to moderate (Fleiss' κ = 0.28 [CI95 0.22-0.34] to 0.38 [CI95 0.33-0.43]).

Conclusion: Conventional MRI-based scores have limited prognostic value and reproducibility in cases of sTBI and are therefore not suitable for accurate and objective neuroprognostication.

Background: Traumatic brain injury (TBI) is recognized as a significant global public health issue associated with high morbidity and mortality. This study aimed to overcome the limitations of traditional prognostic models (e.g., International Mission on Prognosis and Analysis of Clinical Trials, IMPACT) by evaluating the red cell distribution width-to-serum calcium ratio (RCR) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) to determine their prognostic value among patients with moderate-to-severe TBI.

Methods: We retrospectively analyzed 210 consecutive patients admitted to the Trauma Center and Department of Neurosurgery, First Affiliated Hospital of Soochow University (January 2023-January 2025). Demographic, clinical, laboratory, and radiological data were collected. The primary endpoint was 6‑month unfavorable outcome (Glasgow Outcome scale score < 4). Associations between biomarkers and outcome were estimated using multivariable logistic regression. Nonlinearity was examined with restricted cubic splines. Discrimination was compared using receiver operating characteristic curves.

Results: Higher RCR and NT‑proBNP were independently associated with unfavorable outcome [adjusted OR for RCR, 4.871; 95% CI 1.929-12.300; adjusted OR for ln(NT‑proBNP), 2.495; 95% CI 1.648-3.776; both p < 0.001]. Rates of unfavorable outcome rose across RCR tertiles (21.4%, 47.9%, and 63.8%; p < 0.001). Adding both biomarkers to the IMPACT model improved discrimination (AUC 0.924 vs. 0.874; p < 0.001).

Conclusions: Combined assessment of RCR and NT-proBNP enhances early prognostic accuracy in moderate-to-severe TBI, supporting their potential role as accessible biomarkers for refined risk stratification and individualized management.

Objectives: To analyze trends in the prevalence of medical complications in aneurysmal subarachnoid hemorrhage (aSAH) hospitalizations in the USA over the last decade.

Methods: A serial cross-sectional study was performed using the 2006-2022 National Inpatient Sample. Adult (≥ 18 years) primary aSAH hospitalizations with and without complications were identified using International Classification of Diseases codes. Negative binomial regression models were used to evaluate the associations between complications, individualized hospitalization characteristics, and hospital outcomes.

Results: Of 163,349 aSAH hospitalizations over the study period, 68.2% were female. The mean age was 55.6 years, and this increased over time (p-trend < 0.001). The mean National Inpatient Sample Subarachnoid Severity Score was 5.5 [standard error (SE) 0.06] and this also increased over time. Overall, 42.4% of hospitalizations had ≥ 1 medical complication. Urinary tract infections (UTI) (19.4%), pneumonia (15.4%), and sepsis (8.0%) were the most prevalent complications, while acute renal failure (ARF) (7.8%) was the most frequent noninfectious complication. The age- and sex-standardized prevalence of any medical complication remained stable over this study period, but there was marked heterogeneity in prevalence trends by complication type. ARF prevalence increased by nearly 300% [prevalence rate ratio (PRR): 1.04 per year, 95% confidence interval (CI): 1.02-1.04, p < 0.001] and deep venous thrombosis (DVT) prevalence increased by more than 200% (PRR:1.03, 95% CI: 1.01-1.04, p < 0.001) per year, while UTI and sepsis prevalence declined over this time (all p-trend < 0.001). Pneumonia prevalence declined in male only (p-trend < 0.05). Clipping was associated with higher DVT risk (PRR 1.24, 95% CI: 1.13-1.37) but lower gastrointestinal bleeding risk (PRR 1.14, 95% CI: 0.95-1.38) compared with coiling. All complications were significantly linked to poor outcomes (e.g., pneumonia: PRR 1.23, 95% CI: 1.20-1.30).

Conclusions: The prevalence of infectious complications in aSAH has declined over the last decade, but this has been counterbalanced by a troubling increase in ARF and DVT prevalence. Given the strong association of all complications with poor outcomes, future studies focused on mitigating the prevalence of complications are needed to help improve aSAH outcomes.

Introduction: While individually both traumatic brain injury (TBI) and traumatic spinal injury have been studied extensively, the relationship between concurrent TBI and spinal column and/or cord injuries has not. We aimed to identify basic epidemiology, patterns of injury, and patient outcomes from a population served by a tertiary neurosurgery center.

Methodology: A database was built of patient data on admissions to an adult intensive care unit with a TBI over a 12-year period. Electronic patient records, sourced from the database of the Scottish Intensive Care Society Audit Group (SICSAG), were analyzed retrospectively to identify patients who had suffered both a TBI and a concomitant spinal column/cord injury. Data were analyzed on demographics, mechanism of injury, neurological parameters on arrival, clinical management, discharge destinations, and patient outcomes.

Results: Out of 560 patients admitted to ICU with TBI, 85 (85/560; 15.2%) were found to have concomitant spinal injuries. Concomitant thoracolumbar spinal injuries (34/85) were more common than cervical spine injuries (30/85), with 21 patients sustaining both cervical and thoracolumbar injuries. Among the concomitant brain and spinal trauma, spinal cord injuries (SCI) were identified in 16/85 patients (16/560; 2.9%). Outcome assessment revealed 18/85 mortality during index admission, while 36/85 patients required further neurorehabilitation. Concomitant spinal injury was associated with more severe TBI, with 60/85 patients having GCS ≤ 8, and poorer outcomes, with 20% of patients dying during admission. Dichotomizing between cervical and thoracolumbar regions, more SCIs occurred in cervical (10/85) than thoracolumbar (6/85) trauma. SCIs were more pronounced if GCS ≤ 8.

Conclusions: Among TBI requiring ICU admission, there were 15.2% concomitant spinal column injuries, including 2.9% SCI. Lessons on the patterns of concomitant craniospinal injury and their outcomes can help stratify resources, improve the assessment and diagnosis of such complex trauma, and guide future protocols to improve patient outcomes.

Background: Understanding how clinicians prognosticate is important for creating interventions that improve current practice and clinical trials. We compared clinicians' reported approaches to prognostication with traumatic brain injury (TBI) and comatose cardiac arrest (CA) for patients enrolled in a multicenter clinical trial.

Methods: We conducted semi-structured interviews with clinicians who treated patients with severe traumatic brain injury (TBI) enrolled in the Brain Oxygen Optimization in Severe TBI Phase-3 (BOOST-3) trial (NCT03754114). We compared these reports with ones in a previous study of patients who were comatose after cardiac arrest (CA) and were enrolled in the Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients (ICECAP) trial (NCT04217551). We performed deductive coding using our codebook from CA interviews and then used inductive coding to add new topics raised in the TBI interviews. We looked specifically for reported reliance on initial "clinical gestalt" as observed in the CA interviews.

Results: We interviewed 18 clinicians at 13 hospitals. Predicting poor outcomes was less common with TBI cases than in the CA study, consistent with records showing that final prognostication was determined later in the TBI cases (7 [interquartile range (IQR) 2-18.5] vs. 3 [IQR 2-7] days). Similar percentages of clinicians reported high confidence in their initial prognostic assessments in the two settings (TBI, 33%; CA, 40%). Fewer clinicians reported relying on initial clinical gestalt predictions with patients with TBI (22%) than with patients who had experienced CA (70%). With patients with TBI, more clinicians reported having used later subjective assessments to revise their initial uncertain prognostication.

Conclusions: In interviews with clinicians practicing at multiple institutes, we found that clinicians were less likely to report relying on initial gestalt impressions with patients with TBI than with patients who had experienced CA and were more likely to report relying on later subjective assessments to refine uncertain initial prognostic judgments. Fewer clinicians reported high confidence in initial assessments of patients with TBI.