Neurocritical Care最新文献

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.

Background: Electroencephalography (EEG) is a critical tool for neuromonitoring and neuroprognostication in children with acute brain injury. Quantitative EEG (qEEG), particularly the alpha-delta ratio (ADR), can detect worsening cerebral ischemia in adults, but it is unknown whether it can identify more subtle and transient changes in cerebral blood flow, such as those induced by hypertonic saline (HTS), in children with acute brain injury. We aimed to determine whether we could identify a cohort of patients with an ADR response to HTS and to evaluate the association between an ADR response and neurologic outcomes in critically ill children with acute brain injury.

Methods: We conducted a retrospective cohort study of patients admitted to a pediatric intensive care unit with acute brain injury who received HTS during EEG monitoring from 2018 to 2023. The ADR was calculated before and after HTS administration. An ADR response was defined as a > 20% increase from baseline to within 30 min of receiving HTS in either hemisphere. The primary outcome was survival with favorable neurologic outcome, defined as a Functional Status Scale score change < 3 from prehospital baseline to discharge. Secondary outcome was survival to hospital discharge.

Results: Among 87 patients (median age 10 years [interquartile range 3.6-14.5], 46% female), 28% (24 of 87) had an ADR response to HTS. ADR responders were older (12.9 vs. 8.0 years; p = 0.004) and more likely to have continuous, normal-voltage EEG backgrounds (67% vs. 40%; p = 0.006). Patients with an ADR response had four times increased odds of favorable outcome and survival (odds ratio [OR] 4.0 [95% confidence interval (CI) 1.3-12.7] and OR 3.9 [95% CI 1.0-10.7], respectively).

Conclusions: An ADR increase > 20% following HTS was associated with increased odds of survival with favorable neurologic outcome and survival to hospital discharge in critically ill pediatric patients with acute brain injury. qEEG response to HTS may serve as a real-time, noninvasive biomarker of cerebral perfusion responsiveness.

Background: The appropriate timing of tracheostomy in patients with brain injury is debated, with differing opinions on how to improve patient outcomes and limit complications. This study aims to evaluate the association between timing of tracheostomy and resource use (length of stay, hospitalization cost), in-hospital complications (sepsis, acute kidney injury, deep vein thrombosis, pulmonary embolism, ventilator-associated pneumonia, and acute respiratory distress syndrome), and mortality in mechanically ventilated patients with nontraumatic intracerebral hemorrhage (ICH).

Methods: Using the National Inpatient Sample (2012-2022), we identified adult patients with ICH who underwent mechanical ventilation and tracheostomy. Early tracheostomy (ET) was defined as tracheostomy performed within the first 7 days of admission. Clinical variables included demographics, comorbidities, ICH severity markers, and neurosurgical procedures. Outcomes included hospital complications, length of stay, hospitalization cost, and mortality. Propensity score matching (PSM) was applied to adjust for baseline differences, followed by logistic regression analyses to assess outcomes. Subgroup analyses by medically and surgically managed ICHs and age groups were conducted.

Results: Of 3,342 patients with ICH included in the study, 509 (15.2%) underwent ET. Compared to deferred tracheostomy, ET patients were younger (58 [interquartile range (IQR) 49-69] vs. 60 [IQR 51-70] years, p = 0.027) and had a higher rate of hypertension (76% vs. 69.9%, p = 0.005). After 1:1 PSM, ET was associated with reduced risk of sepsis (odds ratio [OR] 0.665, 95% confidence interval [CI] 0.502-0.881, p = 0.004), lower odds of prolonged hospitalization (OR 0.59, 95% CI 0.423-0.823, p = 0.002), and lower hospitalization cost (OR 0.696, 95% CI 0.504-0.961, p = 0.028). There was no significant association with in-hospital mortality. Subgroup analyses demonstrated consistent associations between ET and lower resource use, except in older adults (≥ 80 years). The reduced risk of sepsis was only observed among medically managed patients with ICH and younger individuals.

Conclusions: In patients with ICH requiring mechanical ventilation, ET is associated with shorter length of stay and lower hospitalization cost, except among older adults, without any association with in-hospital mortality. These findings support ET as a potentially beneficial strategy for improving resource efficiency in this patient population.

Background: We sought to assess the prognostic value of incorporating daily inpatient physiological biomarker trajectories to the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model for mortality and morbidity six months after severe traumatic brain injury (TBI).

Methods: Patients with severe TBI (presenting Glasgow Coma Scale ≤ 8) were prospectively collected in a single-center database (n = 598). Morbidity (yes/no) was defined as Glasgow Outcome Scale Extended of 1-4. Daily blood labs (e.g., glucose, sodium, platelets, hemoglobin, neutrophils, lymphocytes, creatinine, blood urea nitrogen) were extracted for the first 14 days after injury. IMPACT was compared with IMPACT-extended (IMPACT + daily lab trajectories) for area under the curve (AUC). Net reclassification index (NRI) assessed the number of correctly reclassified cases for IMPACT-extended compared with IMPACT.

Results: IMPACT-extended had a better AUC than IMPACT for mortality (AUC 0.93 vs. 0.84, P < 0.001) and morbidity (AUC 0.84 vs. 0.80, P < 0.001). NRI analyses revealed IMPACT-extended improved correct classifications of patients who survived to 6 months by 41%. NRI analyses revealed that IMPACT-extended modestly improved correct classification of controls by 4% compared with IMPACT.

Conclusions: Incorporating trajectories for daily blood biomarkers of physiological function significantly improves the discrimination and clinically relevant performance of existing prognostic models for both morbidity and mortality six months following severe TBI.

Background: Status epilepticus (SE) is a heterogeneous disorder with significant morbidity and mortality. This guideline provides broad principles of neuroprognostication and recommendations on the reliability of clinical predictors of outcome that clinicians may consider when counseling surrogate decision-makers of patients with SE.

Methods: This narrative systematic review used Grading of Recommendations Assessment, Development and Evaluation methodology. Good practice recommendations addressed essential principles of neuroprognostication. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and the availability of appropriate evidence. The question was: "When counseling surrogates of patients with SE, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of [outcome] assessed at [time point]?" Outcomes were selected and rated by the panel. Screening criteria were used to exclude smaller and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four Grading of Recommendations Assessment, Development and Evaluation criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use.

Results: Good practice recommendations include establishing appropriate long-term goals with surrogates of patients with SE that may extend beyond seizure control alone, setting expectations for recovery in patients with refractory/super-refractory SE, using predictors specific to underlying pathologies as a basis for neuroprognostication, considering potential confounders, and deferring neuroprognostication in cases of unclear etiology until appropriate diagnostic evaluation is performed. Nine clinical variables and two prediction models were selected. A sufficient body of evidence was available only for the prediction of mortality. Forty-two articles met the eligibility criteria for guiding recommendations. None of the variables and models selected were identified as reliable predictors of mortality in patients with SE.

Conclusions: This guideline provides broad principles for neuroprognostication and recommendations on the reliability of predictors of in-hospital mortality in the context of counseling surrogates of patients with SE.

Background: To develop and validate the first nomogram for the individualized risk assessment of posthemorrhagic chronic hydrocephalus in patients with intraventricular hemorrhage (IVH).

Methods: This multicenter retrospective cohort study analyzed clinical data from patients with IVH treated at seven centers in China between December 2020 and December 2022. The study population specifically comprised patients whose external ventricular drain management was limited to a maximum of 2 weeks, without shunt placement during this period. Patients were randomly categorized into training and validation sets (7:3 ratio). Key predictors were identified using LASSO regression and multivariable logistic regression. Model performance was assessed via the C-index, area under the receiver operating characteristic curve, calibration curves, and decision curve analysis.

Results: A total of 280 patients were included in the study, of whom 82 (29.3%) developed chronic hydrocephalus. Three risk factors, including acute hydrocephalus, ventricular hematoma volume at 24 h, and parenchymal hematoma volume on admission, were identified as significant determinants for chronic hydrocephalus. The nomogram demonstrated robust discriminative ability, with a C-index of 0.850 (95% confidence interval [CI] 0.791-0.909) in the training cohort and 0.785 (95% CI 0.649-0.922) in the validation cohort, surpassing the threshold of 0.70 for clinical utility. The area under the receiver operating characteristic curve was found to be 0.826 (95% CI 0.756-0.896) in the training set and 0.785 (95% CI 0.661-0.910) in the validation set. Furthermore, calibration curves and the Hosmer-Lemeshow test revealed favorable agreement between the nomogram model and actual observations. Decision curve analysis indicated that the nomogram provided clinical net benefit across threshold probabilities ranging from 8 to 80% in the training set and from 18 to 95% in the validation set.

Conclusions: This study developed and validated the first nomogram for assessing the risk of posthemorrhagic chronic hydrocephalus in patients with IVH, providing a valuable tool for individualized risk stratification and clinical decision-making. The study was registered on medicalresearch.org.cn (MR-50-23-048489).

Background: Cerebral autoregulation is routinely assessed through variations in intracranial pressure (ICP) and systemic hemodynamic parameters; however, its metabolic dimension remains underexplored in clinical settings. This study introduces the carbon dioxide reactivity index (CO₂Rx), a novel metric derived from continuous ICP and end-tidal CO₂ (ETCO₂) monitoring aimed at capturing real-time cerebrovascular metabolic reactivity in patients with severe traumatic brain injury (TBI).

Methods: We performed a retrospective observational analysis of patients with moderate and severe TBI admitted to a single adult and pediatric trauma center. CO₂Rx was calculated as a moving Pearson correlation between ICP and ETCO₂ across 60-min windows using low-frequency time-series data. Heatmaps and contour plots visualized median CO₂Rx values across ICP and ETCO₂ ranges. Analyses were stratified by age, decompressive craniectomy status, and 12-month outcomes. A graphical framework linked CO₂Rx/ICP/ETCO₂ combinations to outcome probabilities.

Results: A total of 218 patients (178 adults, 40 pediatric patients) were included. Higher CO₂Rx values, indicative of preserved metabolic reactivity, were observed when ICP was ≤ 20 mm Hg, and ETCO₂ ranged between 30 and 40 mm Hg (median: 0.27; interquartile range [IQR]: 0.20-0.37). In contrast, elevated ICP (> 20 mm Hg) and reduced ETCO₂ (20-30 mm Hg) were associated with lower CO₂Rx values (median: 0.09; IQR: - 0.02 to 0.15), suggesting impaired reactivity. A positive correlation emerged between CO₂Rx and cerebral perfusion pressure, peaking at 60-75 mm Hg (r = 0.31; p < 0.001). Patients with favorable outcomes displayed higher CO₂Rx values, especially within optimal ICP and ETCO₂ ranges, whereas lower values were associated with poorer outcomes.

Conclusions: CO₂Rx is a promising marker of cerebrovascular metabolic reactivity in TBI, offering novel insights into the dynamic relationship between ICP and ETCO₂. It may aid in detecting autoregulatory dysfunction and guide individualized strategies for ventilation, CO₂ control, and surgical decisions. Prospective validation is warranted to confirm its clinical relevance.

Clinical trial registration: ClinicalTrials.gov identifier: NCT05043545.

Background: Teleneurocritical care (TeleNCC) aims to project expertise to hospitals lacking dedicated neurocritical care. However, its influence on clinical care remains underexplored.

Methods: We prospectively studied two TeleNCC cohorts. Within a tertiary care medical decision-making cohort, TeleNCC consultants documented recommended changes in prespecified aspects of evaluation and management for patients at a tertiary care hospital with neurosurgery, neurology, and critical care but without dedicated neurocritical care. In a separate community process measure cohort, TeleNCC consultants documented prespecified process measures (consultation duration, transfer to tertiary care versus local patient retention, and approaches to brain death determination) for patients across ten community hospitals lacking on-site neurology support. Differences were evaluated by site and diagnosis.

Results: Within the tertiary care medical decision-making cohort (n = 123), TeleNCC consultants recommended changes in evaluation and management for 71.8% of patients, including neuroimaging, neuromonitoring, medication initiation/adjustment, operative management, and de-escalation from critical care. TeleNCC consultations often did not require video evaluation. Within the community process measure cohort (n = 1493), consultation duration varied by site. Tertiary care transfer was rare (0-9.2% among 9 of 10 hospitals), although patients with subarachnoid hemorrhage (SAH) were transferred more frequently (38.5%; p < 0.001) than patients with toxic-metabolic/systemic encephalopathy, hypoxic-ischemic encephalopathy, or other cerebrovascular disorders. Community hospital providers evaluated 47 patients for brain death under TeleNCC guidance; 16 (61.5%) of 26 patients evaluated by clinical criteria alone met criteria, as well as 16 (76.2%) of 21 patients evaluated via additional ancillary testing.

Conclusions: For patients at a tertiary care hospital, TeleNCC consultants recommended changes in medical decision-making for the vast majority of patients, whereas community hospital patients receiving TeleNCC consultation as their initial neurologic evaluation rarely required transfer to tertiary care, despite complex conditions, including suspected brain death. These observational cohorts demonstrate the versatility and efficiency of TeleNCC across care settings, although interventional studies are needed to evaluate the impact of TeleNCC on clinical outcomes.