Neurocritical Care最新文献

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.

Patients with disorders of consciousness (DoC) characteristically lack decision-making capacity, a central challenge for shared decision-making, as surrogate decision-makers must navigate the uncertainties of making proxy care decisions. The element of uncertainty is especially prominent considering growing recognition of cognitive motor dissociation or covert consciousness, attributable to advances in neurotechnologies that enable the detection of signatures of responsiveness and recovery capacity that evade routine bedside detection. Professional society guidelines now recommend use of advanced neurotechnologies for some patients, marking their transition from investigational into guideline-directed clinical tests. Yet, advanced neurotechnologies themselves introduce uncertainties to the calculus of shared decision-making, particularly given a paucity of guidance on clinical translation. Through semistructured interviews, we examined attitudes of clinicians and family members of patients with potential covert consciousness during three stages of conversation regarding translation of advanced neurotechnologies into DoC practice. Although clinicians described weighing clinical, prognostic, and logistical factors when deciding to introduce advanced testing, most family members regarded clinicians as ethically obligated to offer advanced neurotechnologies in DoC assessment. There was near consensus that results of advanced neurotechnologies must be shared, even in research contexts. The majority of clinicians and family members posited that results of advanced neurotechnologies should be communicated in ways that are sensitive to families' understanding, background, receptiveness to information, and anticipated decision-making role, and they valued transparency regarding the limitations and uncertainties inherent to these modalities. Clinicians placed higher weight on positive rather than negative results. Half of family members reported that results of advanced neurotechnologies impacted care decisions for their loved ones with DoC. Our findings reveal key points of convergence and divergence between clinicians and family members throughout stages of decision-making, grounding an ethically informed discussion guide that clinicians may use as a roadmap to support shared decision-making in this emerging context.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a severe condition associated with significant morbidity, mortality, and disability. In-hospital care of aSAH is complex and resource intensive, posing substantial financial challenges to health care systems. To support efficient resource allocation, health policy decision-making, and care optimization, this systematic review aimed to assess and synthesize literature on direct in-hospital costs of aSAH management.

Methods: A comprehensive search was performed in July 2025 across PubMed, Medline, Web of Science, Cochrane Library, Emcare, Embase (Ovid), and PsycINFO to identify studies reporting direct in-hospital costs related to aSAH. Reporting completeness and risk of bias were assessed using the Consolidated Health Economic Evaluation Reporting Standards 2022 and the Joanna Briggs Institute checklists. Reported costs were narratively synthesized and converted to 2024 US dollars using the CCEMG-EPPI-Centre Cost Converter. In addition, a random-effects meta-analysis was conducted to compare in-hospital costs between surgical clipping and endovascular coiling.

Results: The database search identified 1,591 articles, of which 30 were included. The average reporting completeness was 74% (range 46-91%) and methodological quality 76% (range 41-100%). Reported in-hospital costs ranged from $11,884 to $459,579 (median $68,711), being the highest in North America, followed by Europe and Asia. Costs as a percentage of gross domestic product per capita ranged from 35 to 639%. Key cost drivers included length of stay, clinical severity, and complications. The meta-analysis found no significant cost difference between clipping and coiling (mean difference $3,057, 95% confidence interval -$11,597 to $17,710).

Conclusions: In-hospital costs for aSAH management are substantial and vary widely due to differences in health care systems, study methodology, and clinical practices. The quality of economic evaluations remains inconsistent, underscoring the need for more standardized and transparent methodologies. As global health care spending increases, high-quality economic evidence is essential for equitable and sustainable care.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) carries high morbidity and mortality. The Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) and its extended version SEBES 6c are computed tomography (CT)-based markers of early brain edema, but their prognostic value remains uncertain. Radiomics enables quantitative characterization of imaging features beyond the visual assessment. Our objective was to compare the predictive performance of SEBES, SEBES 6c, a radiomic SEBES surrogate, and outcome-specific radiomic models for functional outcome, vasospasm, and hydrocephalus after aSAH.

Methods: We retrospectively analyzed 405 patients with aSAH (2007-2024). SEBES and SEBES 6c were visually scored on admission CT scans by anonymized observers. Radiomic features were extracted from gray and white matter, and models were trained either to reproduce SEBES (radiomic SEBES) or to directly predict outcomes. Multivariable analyses combined radiomic and clinical variables to assess prognostic performance. Model generalizability was additionally evaluated in an independent external cohort.

Results: SEBES and SEBES 6c alone showed poor discrimination for six-month functional outcome and lost significance after adjustment for World Federation of Neurological Surgeons and modified Fisher scores. The radiomic SEBES model accurately replicated the visual score but did not predict clinical outcomes. In contrast, outcome-specific radiomic models improved discrimination, particularly when combined with clinical variables, achieving the best predictive accuracy. When applied to the external cohort, the radiomics and clinical model preserved its discriminative ability, demonstrating robustness across data sets.

Conclusions: SEBES and SEBES 6c reflect visible CT edema but provide limited independent prognostic information. Radiomics offers a quantitative and reproducible alternative that complements, rather than replaces, clinical assessment. Outcome-specific radiomic models, especially when integrated with established clinical variables, show promise for improving prognostic stratification after aSAH, although external multicenter validation remains essential.