Neurocritical Care最新文献

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.

Background: Patient differences from optimal mean arterial pressure (MAP_OPT) derived by a cerebral oximetry index (COx_a) are associated with outcome, but the validity of COx_a-derived MAP_OPT remains in question due to the lack of agreement with pressure reactivity index (PRx)-derived MAP_OPT. The study aimed to elucidate the relationship between PRx and COx_a to justify the use of COx_a and COx_a-derived MAP_OPT in patients with aneurysmal subarachnoid hemorrhage (aSAH).

Methods: This was a retrospective single-center study of six patients with aSAH with simultaneous near-infrared spectroscopy, intracranial pressure, and MAP monitoring. Repeated-measures Pearson correlation and Bland-Altman plot analysis were performed to compare PRx and COx_a and to compare PRx-derived MAP_OPT and COx_a-derived MAP_OPT. Coinciding changes in PRx and COx_a were compared, and the ability of COx_a to detect PRx-based autoregulation impairment was assessed over different time windows.

Results: Repeated-measures Pearson correlation analysis showed no correlation between PRx and COx_a (r = 0.06, p < 0.01). The correlation between PRx- and COx_a-derived MAP_OPT over 388 h was r = 0.50 (p < 0.01). The bias and upper and lower limits of agreement were - 1.60, + 20.24, and - 23.43 mm Hg, respectively. The shift in the overall distribution of moving correlation to higher values as the time-window length increased was more pronounced for COx_a than PRx (COx_a: 0.09-0.41, PRx: 0.00-0.15). When using a typical PRx threshold of 0.3, COx_a was found to be ineffective in identifying impaired autoregulation across all time windows (area under the receiver operating characteristic curve: 0.494-0.527).

Conclusions: The threshold applied to PRx should not be applied to COx_a. It is suggested to consider higher thresholds for COx_a than PRx in deriving the range for MAP_OPT calculations for continuous cerebral autoregulation assessment in aSAH. Further research is needed to optimize the MAP_OPT derived from PRx and COx_a based on specific monitoring targets.

Background: Hemorrhagic transformation (HT) remains a common and serious complication after endovascular treatment (EVT) for acute ischemic stroke (AIS). Limited data exist on how dynamic status of leptomeningeal collaterals influence HT in AIS. This study aims to investigate the impact of dynamic status of leptomeningeal collaterals on postoperative HT in patients with AIS undergoing EVT.

Methods: A prospective cohort study was performed between January 2019 and June 2023. Only patients with middle cerebral artery occlusion who received EVT were included. Preoperative leptomeningeal collaterals were evaluated using the regional leptomeningeal collateral (rLMC) score, and postoperative collaterals were assessed using the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology score.

Results: A total of 342 patients with middle cerebral artery occlusion were included in this study. Multivariate analysis demonstrated that patients with good rLMC scores (˃ 10) experienced fewer HT events compared with those with poor rLMC scores (≤ 10) (adjusted odds ratio [aOR] 0.46, 95% confidence interval [CI] 0.28-0.76, P = 0.002). Further subgroup analysis based on intravenous thrombolysis showed that good leptomeningeal collaterals were significantly associated with reduced risk of HT in patients receiving bridging therapy (aOR 0.12, 95% CI 0.03-0.38, p < 0.001). Among 75 patients with incomplete recanalization, analysis of collateral changes indicated that patients with consistently good preoperative and postoperative collateral had the lowest risk of HT (aOR 0.19, 95% CI 0.04-0.95, P = 0.043). However, no significant correlation was detected between symptomatic intracranial hemorrhage and preoperative and postoperative collateral or its dynamic evolution.

Conclusions: Good preoperative leptomeningeal collateral status is associated with reduced risk of HT and better 90-day functional outcomes after EVT, possibly due to its role in maintaining cerebral perfusion and slowing infarct growth. Although our findings suggest that collateral-dependent infarct growth may be a potential mechanism for HT and unfavorable outcomes, this hypothesis requires further investigation.

Despite numerous advances in stroke care over the last decades, financial and structural barriers limit the effective incorporation of these therapies globally. The aim of this narrative review is to examine challenges and propose context-specific strategies to improve neurocritical stroke care in low-resource settings. Short-term treatment of severe strokes can be particularly challenging in low- and middle-income countries (LMIC) due to the inadequate infrastructure of intensive care units, with limited resources and lack of specialized training. For greater effectiveness of neurocritical care treatment of patients with stroke in LMIC, a broad and holistic approach is necessary, including developing clinical protocols adapted to local realities, ensuring the employment of cost-effective interventions and the financial sustainability of health systems. Innovative solutions with wearables and artificial intelligence are leading the way in improving clinical monitoring of patients in regions with limited resources. Continuous improvements are also possible through international collaborations and long-term investment in sustainable local health systems. Finally, addressing socioeconomic and cultural barriers and ensuring access and equity through strategic investments and policies that promote universal health coverage are essential steps in reducing the burden of stroke worldwide.

Background: Lower mean Hounsfield unit (mHU) values, indicating greater computed tomography (CT) hypodensity of perihematomal edema (PHE), have been proposed as a novel quantitative imaging marker in intracerebral hemorrhage (ICH). We explored its evolution and prognostic importance in a post hoc analysis of the Intracerebral Hemorrhage-Deferoxamine trial (NCT02175225).

Methods: We included participants with primary supratentorial ICH who had available CT scans at baseline and follow-up after 72-96 h and 90-days and/or 180-days outcome data. The primary exposure variable was the mHU of PHE measured on the follow-up CT scan. We investigated (1) its change from baseline and (2) its association with unfavorable outcome (modified Rankin Scale score 3-6) in adjusted mixed-effects models, accounting for between-center and between-participant variability.

Results: Among 273 of 293 Intracerebral Hemorrhage-Deferoxamine trial participants eligible for analysis (median age 61 years, 39% female), the median (interquartile range) mHU of PHE was 30.3 (28.3-32.7) at baseline and 26.9 (24.6-29.2) at follow-up. Τhe mHU of PHE decreased from baseline to follow-up scan by an average of 3.6 (95% confidence interval [CI] 3.2-4.0, p < 0.001). There was no association between the mHU of follow-up PHE with unfavorable outcome at 90 days (n = 273; odds ratio 1.05, 95% CI 0.95-1.17, p = 0.32), or at 180 days (n = 261; odds ratio 1.01, 95% CI 0.92-1.11, p = 0.81).

Conclusions: Perihematomal edema after ICH tends to grow more hypodense on CT by day 3-4 compared with baseline. The degree of PHE hypodensity was not associated with long-term clinical outcomes in the setting of a multicenter randomized trial, challenging its utility as a radiological marker in ICH research.

Clinical trial registration: ClinicalTrials.gov: NCT02175225.