Neurocritical Care最新文献

Background: Family caregivers of patients with severe acute brain injury (SABI) who commit to tracheostomy and/or percutaneous endoscopic/surgical gastrostomy for the patient often develop chronic emotional distress. To inform future interventions to mitigate this distress, we characterized the stressors and coping strategies of caregivers of patients with SABI with varying levels of emotional distress during the acute and postacute stages of treatment.

Methods: We conducted semistructured interviews with family caregivers of patients with SABI around the time of neurological intensive care unit discharge (T1) and at 2-month follow-up (T2). All caregivers included in this current study completed the Hospital Anxiety and Depression Scale at T1 and/or T2. We then stratified transcripts by caregiver distress level, characterizing caregivers who scored > 11 on at least one Hospital Anxiety and Depression Scale subscale as "high distress" and ≤ 11 as "low distress." We conducted deductive, conceptual content analysis to compare perceived stressors and coping strategies employed at both time points.

Results: Caregivers in both strata reported many similar stressors at each time point, including ongoing uncertainty. However, there were also differences in stressors by level of distress and time point of assessment. At T1, high-distress caregivers reported pronounced stress related to navigating the health care system and communicating with providers, staff, and the patient. At T2, high-distress caregivers noted heightened difficulty with transitioning to long-term caregiving, co-occurring complex emotions, and communication with family and friends. Conversely, low-distress caregivers focused on challenges with team-based medical decision making at T2. Clear differences in coping strategies also emerged, such that high-distress caregivers relied primarily on avoidance at both points, whereas low-distress caregivers incorporated more problem-solving and self-care strategies.

Conclusions: Psychosocial interventions for caregivers of patients with SABI are needed to reduce emotional distress. Skills should be applied to relevant topics based on time since neurological intensive care unit discharge and distress level. Skills should focus on reducing avoidance, promoting active coping, and targeting the perceived stressors specific to high-distress versus low-distress caregivers revealed here.

Background: The objective of this study was to evaluate whether paroxysmal slow wave events (PSWEs) identified in early electroencephalography (EEG) predict posttraumatic epilepsy (PTE) and disability outcomes following severe traumatic brain injury (sTBI).

Methods: A retrospective case-control study included 45 patients with sTBI (17 with PTE and 28 without PTE) matched by age and Glasgow coma scale. Clinical and EEG data were analyzed. Logistic regression and leave-one-out cross-validation (LOOCV) assessed PTE risk and disability. The area under the curve (AUC) measured accuracy.

Results: Patients with PTE had longer time in PSWEs (P = 0.04) and lower median power frequency (MPF) of PSWEs (P = 0.02) on initial EEGs, along with increased time in PSWEs between initial and follow-up EEGs (P = 0.03). Lower MPF was associated with increased PTE risk (odds ratio 5.88; P = 0.04). Multivariate regression identified hemicraniectomy, time in PSWEs, and MPF as PTE predictors (AUC 0.87; P < 0.0001), maintaining strong LOOCV performance (AUC 0.83; P < 0.0001, accuracy 80%). Longer time in PSWEs was observed in patients with severe disability at the 3-, 6-, and 12-month follow-ups compared with moderate-to-good recovery (P = 0.012, 0.006, and 0.04, respectively).

Conclusions: PSWEs predict PTE development and are more prevalent among patients with worse disability after sTBI. Quantitative PSWE analysis may guide preventive and therapeutic strategies for PTE.

Over the last decade, there has been an increased focus on incorporating palliative care principles into the practice of neurocritical care and emergency medicine (EM). In this article, we describe three different roles that EM clinicians can fill as they initiate the provision of primary neuropalliative care to neurocritically ill patients: the stage setter, the spokesperson, and the screener. As the stage setter, EM clinicians start to build trust with the family by "breaking bad news"; encouraging them to consider the patient's values, preferences, functional baseline, and directives; and providing support to the family during this emotional time as they hand them over to the admitting team who will continue this conversation. As the spokesperson, EM clinicians are involved in early treatment decisions, including whether the patient is admitted to the acute care service or the intensive care unit or transferred to a tertiary care facility, with the goal of preventing both the overuse and underuse of life-sustaining treatment. Lastly, as the screener, EM clinicians have a role to ensure that patients with chronic neurological diseases and patients with a medical history that puts them at high-risk of developing a neurological emergency have goals-of-care conversations and have acceptable control of their daily symptom burden. Further investigation is needed before interventions targeting the practice of neuropalliative care in the emergency department can be developed.

Background: Targeted temperature management (TTM) has been associated with neurological recovery among comatose survivors of cardiac arrest. The aim of this study is to determine whether models leveraging acute phase multimodal data after intensive care unit admission (hyperacute phase) can predict short-term outcome after TTM.

Methods: Clinical, physiologic, and laboratory data in the hyperacute phase were analyzed from adult patients receiving TTM after cardiac arrest. Primary end points were survival and favorable neurological outcome. Three machine learning algorithms were trained: generalized linear models, random forest, and gradient boosting. Models with optimal features from forward selection were tenfold cross-validated and resampled 10 times.

Results: The generalized linear model performed best, with an area under the receiver operating characteristic curve ± standard deviation of 0.86 ± 0.04 for the prediction of survival and 0.85 ± 0.03 for the prediction of favorable neurological outcome. Features most predictive of both end points included lower serum chloride concentration, higher serum pH, and greater neutrophil counts.

Conclusions: We found that in patients receiving TTM after cardiac arrest, short-term outcomes can be accurately determined using machine learning applied to data routinely collected in the first 12 h after intensive care unit admission. With validation, hyperacute prediction could enable personalized decision-making in the postcardiac arrest setting.

Background: Lance-Adams syndrome (LAS) is a rare neurological complication following cardiopulmonary resuscitation. Patients present with action myoclonus within days to months after awakening. There is no established first-line treatment. The objectives of this study were to describe treatments, diagnostic approaches, and long-term clinical outcomes for LAS.

Methods: We performed a retrospective review of patients seen at three tertiary referral hospitals. An electronic database was used to identify all patients diagnosed with LAS from January 1, 2010, to June 30, 2022. Demographics, diagnostics, treatments, and long-term clinical outcomes were extracted. Descriptive statistics were completed to summarize treatments, diagnostics, and clinical outcomes, which were assessed by Cerebral Performance Category (CPC) at 6 months. Symptom control was defined as minimal or no residual myoclonus causing functional impairment on activities of daily living.

Results: Thirty-nine patients met inclusion criteria. A total of 25 patients were diagnosed with LAS during the acute hospitalization after their cardiac arrest, and the rest were diagnosed in the outpatient setting. The most common initial treatment was levetiracetam (n = 26; 67%) followed by valproic acid (n = 4; 10.3%). Most patients initially treated with levetiracetam (n = 22; 85%) or valproic acid (n = 4; 100%) had symptom improvement. Most patients (n = 28; 72%) required a second medication. The most common second-line agent was a benzodiazepine (n = 13; 48%). Thirty-three patients (85%) had improvement of the myoclonus over time. Thirty (77%) were able to achieve symptom control. The median time to achieve symptom control for patients diagnosed in the inpatient setting was 70 days. At the 6-month follow-up, 8 patients (23%) achieved a CPC score of 1, whereas 11 patients (30%) had a CPC score of 2. Thirteen patients (33%) attempted to wean off their medications, of which six patients (46%) were successful.

Conclusions: Most patients with LAS experienced improvement of their myoclonus while being treated with levetiracetam, valproic acid, or benzodiazepines, although multiple medications and long-term treatment were often used. Half the patients attained favorable functional outcomes at 6 months.

The indications of red blood cell transfusions in the absence of life-threatening bleeding in neurocritical individuals are controversial. Recently, three large randomized controlled trials assessed transfusion strategies in this population, allowing an update of a previous meta-analysis, including a sample seven times bigger than the one analyzed previously. We performed a systematic review and updated meta-analysis of liberal versus restrictive transfusion strategy in patients with acute brain injury, comprising traumatic brain injury (TBI), intracerebral hemorrhage, and subarachnoid hemorrhage. A review protocol was registered on PROSPERO (CRD42024616143). We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials comparing liberal versus restrictive transfusion strategy in neurocritical patients. We used Review Manager 5.4 to apply a random-effects model to pool risk ratios (RRs) and 95% confidence intervals (CIs), as available in the individual studies. Quality assessment was performed through the Cochrane Risk of Bias assessment tool (RoB 2.0 tool). Six randomized clinical trials were included, comprising 2,497 patients, of whom 1,431 presented with TBI. The liberal transfusion strategy led to statistically significant lower rates of unfavorable neurological outcomes compared to the restrictive strategy (RR 0.89; 95% CI 0.83-0.96; p = 0.002; I² = 0%). Although a trend favoring the liberal strategy was observed in most mortality and length of stay outcomes, the pooled analysis did not identify statistically significant differences between the two groups. TBI subgroup analysis led to similar results when compared to the general pooled analysis. The main study limitations include the limited number of studies, the imbalance in study weights within the analyses, and the presence of significant heterogeneity. In conclusion, our results suggest that a liberal transfusion strategy may be beneficial to neurocritical patients in terms of neurological outcome when compared to the restrictive strategy, although our results should be interpreted with caution. Further investigation is needed to provide support for updating guidelines for neurocritical care.

Background: Traumatic brain injury (TBI) poses a significant global health burden, yet treatment options remain limited. Several analyses have demonstrated that targeted temperature management (TTM) is superior to normothermia in improving outcomes for patients with TBI. However, the optimal strategy for implementing targeted temperature management in critically ill patients with TBI remains unclear. This study aimed to evaluate and rank different TTM approaches in patients with TBI using a network meta-analysis with meta-regression of randomized controlled trials (RCTs).

Methods: We performed a Bayesian network meta-analysis using a hierarchical model with Monte Carlo simulation to integrate both direct and indirect evidence. RCTs comparing TTM with normothermia in patients with TBI were included. Primary outcomes were mortality and poor functional recovery. Relative risks (RRs) and 95% credible intervals (CrIs) were reported. The surface under the cumulative ranking curve and forest plots were used to rank and visualize treatment effects.

Results: A total of 30 RCTs involving 3498 participants were included. Surface cooling (RR: 0.54; 95% CrI: 0.43-0.69) and cranial cooling (RR: 0.61; 95% CrI: 0.36-0.98) significantly reduced mortality compared with intravenous or gastric cooling. Moreover, surface cooling (RR: 0.69; 95% CrI: 0.62-0.77) and cranial cooling (RR: 0.44; 95% CrI: 0.29-0.65) were related to better functional outcomes compared with intravenous or gastric cooling. These findings remained robust in the subgroup of patients with severe TBI.

Conclusions: In adults with TBI, targeted temperature management delivered via surface or cranial cooling reduces mortality and improves functional recovery compared with other cooling methods. Large-scale randomized controlled trials are warranted to further validate our results and to investigate the impact of different target temperature settings on patient outcomes.

Background: Platelet dysfunction in the setting of intracranial hemorrhage may potentiate worsening hemorrhage. Desmopressin may be used to treat platelet dysfunction in intracranial hemorrhage through von Willebrand factor release. Hypertonic saline is often used in this population to treat cerebral edema and elevated intracranial pressure. Free water reabsorption associated with desmopressin may attenuate the effect of hyperosmolar therapy. The effect of desmopressin on continuous infusion 3% sodium chloride (3%) when targeting a specific sodium goal has not been definitively elucidated. We hypothesize that a lower proportion of patients treated with desmopressin will have achieved a serum sodium of ≥ 150 mEq/L at 48 h versus those that did not receive desmopressin.

Methods: This is a retrospective cohort study at a level-1 trauma center and quaternary care center that included patients who received 3% infusions for at least 48 h following admission in the setting of intracranial hemorrhage of varying etiologies. The primary end point is the proportion of patients reaching a serum sodium of ≥ 150 mEq/L within 48 h of 3% initiation. To account for confounding variables, a logistic regression adjusted analysis was also performed to evaluate the primary end point.

Results: A total of 127 patients were included in this study; 75 were not treated with desmopressin, and 52 were treated with desmopressin. There was no significant difference noted in the attainment of serum sodium of 150 mEq/L within 48 h of 3% therapy in the control versus desmopressin group (47 [62.7%] vs. 34 [65.4%]; P = 0.7540). Adjusted logistic regression evaluating the effect of DDAVP on sodium goal attainment did not reach statistical significance (odds ratio 1.59 [95% confidence interval 0.56-4.52], P = 0.3851).

Conclusions: Desmopressin does not appear to affect the ability to attain a therapeutic hypernatremia goal of ≥ 150 mEq/L within 48 h when using continuous infusion hypertonic saline.