Neurocritical Care最新文献

Background: Anti-N-methyl D-aspartate-receptor encephalitis (anti-NMDARe) is a severe disease with a favorable outcome when immunomodulatory management is started rapidly. The main objective of this study is to compare the early efficacy of the two most frequently used therapeutics, i.e., intravenous immunoglobulin (IVIG) and therapeutic plasma exchange (TPE), in intensive care patients admitted for anti-NMDARe.

Methods: This is an observational retrospective study of patients hospitalized in a tertiary medical neurointensive care unit for severe anti-NMDARe. Patients were categorized according to the modality of first-line immunomodulatory therapies associated with corticosteroids: TPE, IVIG, or IVIG followed by TPE. The primary end point was the effectiveness of the first-line immunomodulatory treatment. Treatment was considered effective when no other immunomodulatory therapy was introduced and the patient met the following three conditions: response to simple commands, absence of epileptic seizures, and absence of abnormal movements.

Results: Thirty-seven patients were included in the study from January 2007 to December 2022: 8 were treated with TPE alone, 13 were treated with IVIG alone, and 16 were treated with IVIG followed by TPE. Of the 29 patients treated with IVIG, 13 showed improvement, with a median latency to treatment response of 36 days, whereas 16 were switched to TPE, with a median latency to treatment response of 30 days due to a lack of improvement. All eight patients treated with TPE improved, with a latency to treatment response of 31 days. TPE was significantly more effective than IVIG.

Conclusions: This study raises the hypothesis that immunotherapies may have differential response rates among patients with NMDARe. Although the retrospective nature of the analysis may be subject to bias and confounding, the potential for therapeutic impact deserves prospective evaluation.

Background: The receptor tyrosine kinase AR4-type receptor in erythropoietin-producing hepatocellular carcinoma (EphA4) has been linked to disruption of the blood-brain barrier (BBB) and hemorrhagic transformation after acute ischemic stroke. Here, we explored whether EphA4 may be involved in parenchymal hematoma (PH) after ischemic stroke.

Methods: Data were analyzed from patients who were admitted to West China Hospital of Sichuan University within 48 h of stroke onset between January 2017 and December 2019. EphA4 levels in serum were measured within 24 h after admission, and baseline computed tomography perfusion was performed immediately upon admission. Potential relationships of EphA4 levels or ipsilateral flow extraction product (FED) with occurrence of PH were explored using logistic regression.

Results: Of the 578 patients (337 men) analyzed, who were a median age of 69 years old, 56 (9.69%) developed PH. Serum EphA4 levels were higher in patients with PH than in those without PH (44.96 vs. 37.86 ng/mL, P = 0.036). After adjustment for confounders, higher serum EphA4 levels (≥ 32.21 ng/mL) were significantly associated with PH (odds ratio [OR] 3.84, 95% confidence interval [CI] 1.66-8.90, P = 0.002). Among the 230 patients in whom brain perfusion was analyzed using computed tomography perfusion, ipsilateral FED was significantly associated with PH after adjusting for confounders (OR 2.43, 95% CI 1.63-3.63, P < 0.001). The two parameters of EphA4 level and ipsilateral FED interacted in their association with PH (P_interaction = 0.037): higher EphA4 level was associated with PH in those with higher ipsilateral FED (OR 1.04, 95% CI 1.01-1.07, P = 0.006), not in those with lower FED.

Conclusions: Elevated EphA4 levels in serum are associated with higher risk of PH after ischemic stroke, especially among patients showing greater permeability of the BBB as reflected in higher ipsilateral FED on computed tomography perfusion.