Neurocritical Care最新文献

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.

Background: Super-refractory status epilepticus (SRSE) is a life-threatening neurological emergency with limited treatment options. A ketogenic diet (KD) is increasingly considered as a rescue therapy, but controlled data in critically ill adults remain scarce. This study aimed to evaluate the feasibility, safety, and clinical effects of KD in adult SRSE using a severity-matched control group.

Methods: A retrospective, severity-matched cohort study compared adult patients with SRSE treated with KD to matched controls. The primary outcome was SRSE resolution. Secondary outcomes included the modified Rankin Scale (mRS) and mortality at 3 and 6 months. Time-dependent and multivariate Cox regression models adjusted for illness severity (including age and Status Epilepticus Severity Score [STESS]) and delayed KD initiation. Despite pragmatic matching, baseline differences in age, STESS, and seizure type were addressed through multivariate adjustment.

Results: A total of 34 adult patients with SRSE were analyzed (18 KD, 16 control). KD was initiated after a mean of 16.6 ± 9.4 days and maintained for 12.9 ± 7.7 days. Ketosis was achieved in 33%, with mild, manageable complications in 28%. SRSE resolution occurred in 61.1% of KD patients vs. 87.5% of controls (p = 0.125), although KD patients had significantly longer status epilepticus duration and higher medication burden. Time-dependent Cox regression showed an association with faster SRSE resolution after KD initiation (hazard ratio [HR] 0.26, 95% confidence interval [CI] 0.07-0.97; p = 0.045). In the multivariate Cox model, KD remained independently associated with SRSE resolution (HR 0.368, 95% CI 0.176-0.756; p = 0.006). Earlier KD initiation was independently associated with improved seizure control (p = 0.015). At 3 and 6 months, KD patients showed significantly better functional outcomes (p = 0.023 and p = 0.021, respectively). Ketosis or ketone levels were not associated with outcome, suggesting that therapeutic effects may be independent of measurable ketosis.

Conclusions: KD is feasible and safe in adult patients with SRSE. Time-dependent models showed a significant therapeutic association, particularly with earlier initiation. These findings support prospective evaluation of KD as a nonpharmacologic therapy in neurocritical care.