Neurocritical Care最新文献

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.

Background: Anatomical variations in the Circle of Willis (CoW) may influence hemodynamics and aneurysmal subarachnoid hemorrhage (aSAH) outcomes. We hypothesized that incomplete CoW could alter cerebral blood flow and reduce symptomatic vasospasm risk due to underlying arteriosclerotic changes.

Methods: We analyzed imaging data from patients with aSAH admitted to an academic center from 2015-2022. Patients were categorized by CoW anatomy into two (complete vs. incomplete) and three groups (complete, partial [missing an anterior or posterior component], and disconnected [missing both an anterior and posterior component]). Primary outcomes included radiologic vasospasm (transcranial Doppler [TCD] criteria) and symptomatic vasospasm. Secondary outcomes included delayed cerebral ischemia and three-month functional outcomes (modified Rankin Scale).

Results: Among 286 patients with aSAH (61.5% female; mean age 56.2 ± 13.4 years), 79% had incomplete CoW anatomy and were older than complete CoW patients (57.6 ± standard deviation vs. 50.7 ± standard deviation years, P = 0.003). Univariate analysis revealed lower incidence of symptomatic vasospasm in incomplete CoWs (36% vs. 59%, P = 0.013) without significant differences in TCD-diagnosed vasospasm or functional outcomes. Multivariate analysis confirmed incomplete and disconnected CoWs were associated with lower symptomatic vasospasm risk (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.19-0.93, P = 0.03 and OR 0.27, 95% CI 0.10-0.68, P = 0.007, respectively) with no differences in TCD elevation, delayed cerebral ischemia, or three-month functional outcomes (OR 1.01, 95% CI 0.5-2.0 and OR 0.87, 95% CI 0.37-2.07, respectively).

Conclusions: Incomplete CoW is associated with lower symptomatic vasospasm risk but not with functional outcomes. These findings may reflect physiological arteriosclerotic changes influencing vasospasm risk. Understanding CoW anatomy could assist risk stratification of patients with aSAH, warranting further research into these mechanisms.

Background: Early seizures are a common complication after acute intracerebral hemorrhage (ICH). We tested the hypothesis of whether prophylactic antiseizure medication is associated with lower incidence of early seizures in patients with elevated risk of ICH.

Methods: This study involved a retrospective analysis of a prospective observational cohort, including five academic medical centers with a focus on patients presenting spontaneous ICH on hospital admission in the years 2006 through 2023. We assessed the characteristics of acute ICH and the administration of antiseizure medication. In this observational cohort, the administration of antiseizure medication was at the discretion of the treating physician. We focused on the 300 patients with lobar hematoma location. Age, hematoma volume, and sex were included as covariates in an adjusted regression model to evaluate seizure occurrence. We prospectively recorded the use of antiseizure medications and identified the occurrence of early seizures. Additionally, we conducted an exploratory analysis defining patients who were at risk as those with lobar hematomas, age < 65 years, and hematoma volume ≥ 10 mL. Functional outcomes were assessed using modified Rankin Scale scores three months after event.

Results: The median age was 72.0 (interquartile range 62.0-80.0) years, and 158 (53%) were female. An early seizure occurred in 43 (14.3%). In patients who did not receive antiseizure prophylaxis, 34 of 157 (21.6%) had an early seizure, whereas in patients who did receive antiseizure prophylaxis, 9 of 143 (6.3%) had an early seizure. Prophylactic antiseizure medication was associated with a reduced incidence of early seizures (adjusted odds ratio 0.25, 95% confidence interval 0.11-0.54, P = 0.0005) in patients at high risk for early seizures. There was no association between prophylactic medication use and modified Rankin Scale scores at three-month follow-up.

Conclusions: In a retrospective analysis of a multicenter cohort of patients at elevated seizure risk after ICH, prophylactic antiseizure medication was associated with a reduced likelihood of an early seizure.

Background: Cerebral ischemia is frequently detected after intracerebral hemorrhage (ICH) on diffusion-weighted imaging (DWI) and is associated with worse outcomes. Although the mechanism is uncertain, cerebral autoregulation impairment due to severe hypertension has been suggested from prior studies. We tested the hypothesis that more severe left ventricular hypertrophy (LVH), a marker of chronic hypertension-mediated organ damage, is associated with DWI lesions after ICH.

Methods: Using a single-center observational cohort study, we included all patients with spontaneous ICH between 2009 and 2019 with available magnetic resonance imaging (MRI) who underwent transthoracic echocardiography (TTE) during the index hospitalization. LVH was primarily categorized as none/mild or moderate/severe based on the TTE report and was secondarily defined using calculated left ventricular mass index (LVMI) measurement. The primary outcome measure was acute DWI lesion presence on brain MRI. The number of DWI lesions was assessed as a secondary outcome.

Results: A total of 187 patients (mean [SD] age 66.4 [14.5] years, 50.8% female) with a median baseline ICH volume of 12.6 (interquartile range 4.0-32.0) mL had TTE and DWI performed. Moderate/severe LVH was present in 23.5% of patients, and DWI lesions were detected in 30.5% of the cohort. Using multivariable logistic regression, the primary analysis found that moderate/severe LVH was associated with DWI lesion presence with adjustment for ICH severity (adjusted odds ratio [aOR] 2.74, confidence interval [CI] 1.32-5.71; p = 0.01). A similar association was demonstrated between the highest LVMI quartile and DWI lesion presence (aOR 3.60, CI 1.48-8.77; p = 0.01). Linear regression models found moderate/severe LVH was associated with greater DWI lesion count (adjusted B 1.32, CI 0.89-1.76; p < 0.01).

Conclusions: Greater LVH severity was associated with the presence and burden of DWI lesions after acute ICH. Echocardiography may be a tool to inform secondary ischemia risk stratification and prevention strategies.