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Kenda M, Lang M, Nee J, Hinrichs C, Dell'Orco A, Salih F, Kemmling A, Nielsen N, Wise M, Thomas M, Düring J, McGuigan P, Cronberg T, Scheel M, Moseby-Knappe M, Leithner C. Regional Brain Net Water Uptake in Computed Tomography after Cardiac Arrest - A Novel Biomarker for Neuroprognostication. Resuscitation 2024; 200:110243. [PMID: 38796092 DOI: 10.1016/j.resuscitation.2024.110243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/10/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Selective water uptake by neurons and glial cells and subsequent brain tissue oedema are key pathophysiological processes of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest (CA). Although brain computed tomography (CT) is widely used to assess the severity of HIE, changes of brain radiodensity over time have not been investigated. These could be used to quantify regional brain net water uptake (NWU), a potential prognostic biomarker. METHODS We conducted an observational prognostic accuracy study including a derivation (single center cardiac arrest registry) and a validation (international multicenter TTM2 trial) cohort. Early (<6 h) and follow-up (>24 h) head CTs of CA patients were used to determine regional NWU for grey and white matter regions after co-registration with a brain atlas. Neurological outcome was dichotomized as good versus poor using the Cerebral Performance Category Scale (CPC) in the derivation cohort and Modified Rankin Scale (mRS) in the validation cohort. RESULTS We included 115 patients (81 derivation, 34 validation) with out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA). Regional brain water content remained unchanged in patients with good outcome. In patients with poor neurological outcome, we found considerable regional water uptake with the strongest effect in the basal ganglia. NWU >8% in the putamen and caudate nucleus predicted poor outcome with 100% specificity (95%-CI: 86-100%) and 43% (moderate) sensitivity (95%-CI: 31-56%). CONCLUSION This pilot study indicates that NWU derived from serial head CTs is a promising novel biomarker for outcome prediction after CA. NWU >8% in basal ganglia grey matter regions predicted poor outcome while absence of NWU indicated good outcome. NWU and follow-up CTs should be investigated in larger, prospective trials with standardized CT acquisition protocols.
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Affiliation(s)
- Martin Kenda
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany.
| | - Margareta Lang
- Department of Clinical Sciences Lund, Radiology, Lund University, Helsingborg Hospital, Lund, Sweden
| | - Jens Nee
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Intensive Care Medicine, Circulatory Arrest Center Berlin, Berlin, Germany
| | - Carl Hinrichs
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Intensive Care Medicine, Circulatory Arrest Center Berlin, Berlin, Germany
| | - Andrea Dell'Orco
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Neuroradiology, Campus Charité, Mitte, Germany
| | - Farid Salih
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - André Kemmling
- Department of Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Niklas Nielsen
- Anaesthesiology and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Matt Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | | | - Joachim Düring
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Peter McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK; Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, UK
| | - Tobias Cronberg
- Department of Neurology, Skane University Hospital, Lund, Sweden
| | - Michael Scheel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Neuroradiology, Campus Charité, Mitte, Germany
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology and Rehabilitation, Lund University, Skåne University Hospital, Lund, Sweden
| | - Christoph Leithner
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
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2
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Lang M, Kenda M, Scheel M, Martola J, Wheeler M, Owen S, Johnsson M, Annborn M, Dankiewicz J, Deye N, Düring J, Friberg H, Halliday T, Jakobsen JC, Lascarrou JB, Levin H, Lilja G, Lybeck A, McGuigan P, Rylander C, Sem V, Thomas M, Ullén S, Undén J, Wise MP, Cronberg T, Wassélius J, Nielsen N, Leithner C, Moseby-Knappe M. Standardised and automated assessment of head computed tomography reliably predicts poor functional outcome after cardiac arrest: a prospective multicentre study. Intensive Care Med 2024; 50:1096-1107. [PMID: 38900283 PMCID: PMC11245448 DOI: 10.1007/s00134-024-07497-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE Application of standardised and automated assessments of head computed tomography (CT) for neuroprognostication after out-of-hospital cardiac arrest. METHODS Prospective, international, multicentre, observational study within the Targeted Hypothermia versus Targeted Normothermia after out-of-hospital cardiac arrest (TTM2) trial. Routine CTs from adult unconscious patients obtained > 48 h ≤ 7 days post-arrest were assessed qualitatively and quantitatively by seven international raters blinded to clinical information using a pre-published protocol. Grey-white-matter ratio (GWR) was calculated from four (GWR-4) and eight (GWR-8) regions of interest manually placed at the basal ganglia level. Additionally, GWR was obtained using an automated atlas-based approach. Prognostic accuracies for prediction of poor functional outcome (modified Rankin Scale 4-6) for the qualitative assessment and for the pre-defined GWR cutoff < 1.10 were calculated. RESULTS 140 unconscious patients were included; median age was 68 years (interquartile range [IQR] 59-76), 76% were male, and 75% had poor outcome. Standardised qualitative assessment and all GWR models predicted poor outcome with 100% specificity (95% confidence interval [CI] 90-100). Sensitivity in median was 37% for the standardised qualitative assessment, 39% for GWR-8, 30% for GWR-4 and 41% for automated GWR. GWR-8 was superior to GWR-4 regarding prognostic accuracies, intra- and interrater agreement. Overall prognostic accuracy for automated GWR (area under the curve [AUC] 0.84, 95% CI 0.77-0.91) did not significantly differ from manually obtained GWR. CONCLUSION Standardised qualitative and quantitative assessments of CT are reliable and feasible methods to predict poor functional outcome after cardiac arrest. Automated GWR has the potential to make CT quantification for neuroprognostication accessible to all centres treating cardiac arrest patients.
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Affiliation(s)
- Margareta Lang
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Martin Kenda
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Juha Martola
- HUS Medical Imaging Center, Radiology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Matthew Wheeler
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Stephanie Owen
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Mikael Johnsson
- Department of Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Martin Annborn
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Nicolas Deye
- Department of Medical and Toxicological Intensive Care Unit, Inserm UMR-S 942, Assistance Publique des Hopitaux de Paris, Lariboisière University Hospital, Paris, France
| | - Joachim Düring
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Malmö, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Malmö, Sweden
| | - Thomas Halliday
- Department of Operation and Intensive Care, Linköping University Hospital, Linköping, Sweden
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean-Baptiste Lascarrou
- Medecine Intensive Reanimation, Movement-Interactions-Performance,, Nantes Université, CHU Nantes, MIP, UR 4334, 44000, Nantes, France
| | - Helena Levin
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Research and Education, Skåne University Hospital, Lund, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Anna Lybeck
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Peter McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Christian Rylander
- Anaesthesia and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Victoria Sem
- Department of Anaesthesia and Intensive Care, Central Hospital of Karlstad, Karlstad, Sweden
| | - Matthew Thomas
- Intensive Care Unit, University Hospitals Bristol and Weston, Bristol, UK
| | - Susann Ullén
- Clinical Studies Sweden‑Forum South, Skåne University Hospital, Lund, Sweden
| | - Johan Undén
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Operation and Intensive Care, Hallands Hospital Halmstad, Halmstad, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Johan Wassélius
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Christoph Leithner
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
- Department of Neurology, Skåne University Hospital, Lund, Sweden.
- Department of Rehabilitation, Skåne University Hospital, 22185, Lund, Sweden.
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Benghanem S, Sharshar T, Gavaret M, Dumas F, Diehl JL, Brechot N, Picard F, Candia-Rivera D, Le MP, Pène F, Cariou A, Hermann B. Heart rate variability for neuro-prognostication after CA: Insight from the Parisian registry. Resuscitation 2024:110294. [PMID: 38925291 DOI: 10.1016/j.resuscitation.2024.110294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/31/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Hypoxic ischemic brain injury (HIBI) induced by cardiac arrest (CA) seems to predominate in cortical areas and to a lesser extent in the brainstem. These regions play key roles in modulating the activity of the autonomic nervous system (ANS), that can be assessed through analyses of heart rate variability (HRV). The objective was to evaluate the prognostic value of various HRV parameters to predict neurological outcome after CA. METHODS Retrospective monocentric study assessing the prognostic value of HRV markers and their association with HIBI severity. Patients admitted for CA who underwent EEG for persistent coma after CA were included. HRV markers were computed from 5 min signal of the ECG lead of the EEG recording. HRV indices were calculated in the time-, frequency-, and non-linear domains. Frequency-domain analyses differentiated very low frequency (VLF 0.003-0.04 Hz), low frequency (LF 0.04-0.15 Hz), high frequency (HF 0.15-0.4 Hz), and LF/HF ratio. HRV indices were compared to other prognostic markers: pupillary light reflex, EEG, N20 on somatosensory evoked potentials (SSEP) and biomarkers (neuron specific enolase-NSE). Neurological outcome at 3 months was defined as unfavorable in case of best CPC 3-4-5. RESULTS Between 2007 and 2021, 199 patients were included. Patients were predominantly male (64%), with a median age of 60 [48.9-71.7] years. 76% were out-of-hospital CA, and 30% had an initial shockable rhythm. Neurological outcome was unfavorable in 73%. Compared to poor outcome, patients with a good outcome had higher VLF (0.21 vs 0.09 ms2/Hz, p < 0.01), LF (0.07 vs 0.04 ms2/Hz, p = 0.003), and higher LF/HF ratio (2.01 vs 1.01, p = 0.008). Several non-linear domain indices were also higher in the good outcome group, such as SD2 (15.1 vs 10.2, p = 0.016) and DFA α1 (1.03 vs 0.78, p = 0.002). These indices also differed depending on the severity of EEG pattern and abolition of pupillary light reflex. These time-frequency and non-linear domains HRV parameters were predictive of poor neurological outcome, with high specificity despite a low sensitivity. CONCLUSION In comatose patients after CA, some HRV markers appear to be associated with unfavorable outcome, EEG severity and PLR abolition, although the sensitivity of these HRV markers remains limited.
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Affiliation(s)
- Sarah Benghanem
- Medical Intensive Care Unit, APHP.Paris Centre, Cochin Hospital, Paris, France; University Paris Cité, Medical School, Paris F-75006, France; INSERM 1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM UMR 1266, Paris, France.
| | - Tarek Sharshar
- University Paris Cité, Medical School, Paris F-75006, France; INSERM 1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM UMR 1266, Paris, France; Neuro-ICU, GHU Paris Sainte Anne, Paris, France
| | - Martine Gavaret
- University Paris Cité, Medical School, Paris F-75006, France; INSERM 1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM UMR 1266, Paris, France; Neurophysiology and Epileptology Department, GHU Paris Sainte Anne, Paris, France
| | - Florence Dumas
- University Paris Cité, Medical School, Paris F-75006, France; Emergency Department, APHP.Paris Centre, Cochin Hospital, Paris, France
| | - Jean-Luc Diehl
- University Paris Cité, Medical School, Paris F-75006, France; Medical ICU, AP-HP, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris F-75015, France
| | - Nicolas Brechot
- University Paris Cité, Medical School, Paris F-75006, France; Medical ICU, AP-HP, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris F-75015, France
| | - Fabien Picard
- University Paris Cité, Medical School, Paris F-75006, France; Cardiology Department, APHP.Paris Centre, Cochin Hospital, Paris, France
| | - Diego Candia-Rivera
- Institut du Cerveau et de la Moelle épinière - ICM, INSERM U1127, CNRS UMR 7225, F-75013 Paris, France
| | - Minh-Pierre Le
- Medical Intensive Care Unit, APHP.Paris Centre, Cochin Hospital, Paris, France
| | - Frederic Pène
- Medical Intensive Care Unit, APHP.Paris Centre, Cochin Hospital, Paris, France; University Paris Cité, Medical School, Paris F-75006, France
| | - Alain Cariou
- Medical Intensive Care Unit, APHP.Paris Centre, Cochin Hospital, Paris, France; University Paris Cité, Medical School, Paris F-75006, France
| | - Bertrand Hermann
- University Paris Cité, Medical School, Paris F-75006, France; INSERM 1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM UMR 1266, Paris, France; Medical ICU, AP-HP, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris F-75015, France
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4
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Bang HJ, Youn CS, Sandroni C, Park KN, Lee BK, Oh SH, Cho IS, Choi SP. Good outcome prediction after out-of-hospital cardiac arrest: A prospective multicenter observational study in Korea (the KORHN-PRO registry). Resuscitation 2024; 199:110207. [PMID: 38582440 DOI: 10.1016/j.resuscitation.2024.110207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
AIM To assess the ability of clinical examination, biomarkers, electrophysiology and brain imaging, individually or in combination to predict good neurological outcomes at 6 months after CA. METHODS This was a retrospective analysis of the Korean Hypothermia Network Prospective Registry 1.0, which included adult out-of-hospital cardiac arrest (OHCA) patients (≥18 years). Good outcome predictors were defined as both pupillary light reflex (PLR) and corneal reflex (CR) at admission, Glasgow Coma Scale Motor score (GCS-M) >3 at admission, neuron-specific enolase (NSE) <17 µg/L at 24-72 h, a median nerve somatosensory evoked potential (SSEP) N20/P25 amplitude >4 µV, continuous background without discharges on electroencephalogram (EEG), and absence of anoxic injury on brain CT and diffusion-weighted imaging (DWI). RESULTS A total of 1327 subjects were included in the final analysis, and their median age was 59 years; among them, 412 subjects had a good neurological outcome at 6 months. GCS-M >3 at admission had the highest specificity of 96.7% (95% CI 95.3-97.8), and normal brain DWI had the highest sensitivity of 96.3% (95% CI 92.9-98.4). When the two predictors were combined, the sensitivities tended to decrease (ranging from 2.7-81.1%), and the specificities tended to increase, ranging from81.3-100%. Through the explorative variation of the 2021 European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) prognostication strategy algorithms, good outcomes were predicted, with a specificity of 83.2% and a sensitivity of 83.5% in patients by the algorithm. CONCLUSIONS Clinical examination, biomarker, electrophysiology, and brain imaging predicted good outcomes at 6 months after CA. When the two predictors were combined, the specificity further improved. With the 2021 ERC/ESICM guidelines, the number of indeterminate patients and the uncertainty of prognostication can be reduced by using a good outcome prediction algorithm.
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Affiliation(s)
- Hyo Jin Bang
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Donggu, Gwangju, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - In Soo Cho
- Department of Emergency Medicine, KEPCO Medical Center, 308, Uicheon-ro, Dobong-gu, Seoul, Republic of Korea
| | - Seung Pill Choi
- Department of Emergency Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Republic of Korea
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5
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Preuß S, Multmeier J, Stenzel W, Major S, Ploner CJ, Storm C, Nee J, Leithner C, Endisch C. Survival, but not the severity of hypoxic-ischemic encephalopathy, is associated with higher mean arterial blood pressure after cardiac arrest: a retrospective cohort study. Front Cardiovasc Med 2024; 11:1337344. [PMID: 38774664 PMCID: PMC11106407 DOI: 10.3389/fcvm.2024.1337344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 04/15/2024] [Indexed: 05/24/2024] Open
Abstract
Background This study investigates the association between the mean arterial blood pressure (MAP), vasopressor requirement, and severity of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest (CA). Methods Between 2008 and 2017, we retrospectively analyzed the MAP 200 h after CA and quantified the vasopressor requirements using the cumulative vasopressor index (CVI). Through a postmortem brain autopsy in non-survivors, the severity of the HIE was histopathologically dichotomized into no/mild and severe HIE. In survivors, we dichotomized the severity of HIE into no/mild cerebral performance category (CPC) 1 and severe HIE (CPC 4). We investigated the regain of consciousness, causes of death, and 5-day survival as hemodynamic confounders. Results Among the 350 non-survivors, 117 had histopathologically severe HIE while 233 had no/mild HIE, without differences observed in the MAP (73.1 vs. 72.0 mmHg, pgroup = 0.639). Compared to the non-survivors, 211 patients with CPC 1 and 57 patients with CPC 4 had higher MAP values that showed significant, but clinically non-relevant, MAP differences (81.2 vs. 82.3 mmHg, pgroup < 0.001). The no/mild HIE non-survivors (n = 54), who regained consciousness before death, had higher MAP values compared to those with no/mild HIE (n = 179), who remained persistently comatose (74.7 vs. 69.3 mmHg, pgroup < 0.001). The no/mild HIE non-survivors, who regained consciousness, required fewer vasopressors (CVI 2.1 vs. 3.6, pgroup < 0.001). Independent of the severity of HIE, the survivors were weaned faster from vasopressors (CVI 1.0). Conclusions Although a higher MAP was associated with survival in CA patients treated with a vasopressor-supported MAP target above 65 mmHg, the severity of HIE was not. Awakening from coma was associated with less vasopressor requirements. Our results provide no evidence for a MAP target above the current guideline recommendations that can decrease the severity of HIE.
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Affiliation(s)
- Sandra Preuß
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology and Angiology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Multmeier
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- Ada Health GmbH, Berlin, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph J. Ploner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Nee
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Endisch
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
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6
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Sarton B, Tauber C, Fridman E, Péran P, Riu B, Vinour H, David A, Geeraerts T, Bounes F, Minville V, Delmas C, Salabert AS, Albucher JF, Bataille B, Olivot JM, Cariou A, Naccache L, Payoux P, Schiff N, Silva S. Neuroimmune activation is associated with neurological outcome in anoxic and traumatic coma. Brain 2024; 147:1321-1330. [PMID: 38412555 PMCID: PMC10994537 DOI: 10.1093/brain/awae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 12/22/2023] [Accepted: 01/09/2024] [Indexed: 02/29/2024] Open
Abstract
The pathophysiological underpinnings of critically disrupted brain connectomes resulting in coma are poorly understood. Inflammation is potentially an important but still undervalued factor. Here, we present a first-in-human prospective study using the 18-kDa translocator protein (TSPO) radioligand 18F-DPA714 for PET imaging to allow in vivo neuroimmune activation quantification in patients with coma (n = 17) following either anoxia or traumatic brain injuries in comparison with age- and sex-matched controls. Our findings yielded novel evidence of an early inflammatory component predominantly located within key cortical and subcortical brain structures that are putatively implicated in consciousness emergence and maintenance after severe brain injury (i.e. mesocircuit and frontoparietal networks). We observed that traumatic and anoxic patients with coma have distinct neuroimmune activation profiles, both in terms of intensity and spatial distribution. Finally, we demonstrated that both the total amount and specific distribution of PET-measurable neuroinflammation within the brain mesocircuit were associated with the patient's recovery potential. We suggest that our results can be developed for use both as a new neuroprognostication tool and as a promising biometric to guide future clinical trials targeting glial activity very early after severe brain injury.
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Affiliation(s)
- Benjamine Sarton
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Clovis Tauber
- Imaging and Brain laboratory, UMRS Inserm U930, Université de Tours, F-37000 Tours, France
| | - Estéban Fridman
- Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10065, USA
| | - Patrice Péran
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Beatrice Riu
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Hélène Vinour
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Adrian David
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Thomas Geeraerts
- Neurocritical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Fanny Bounes
- Critical Care Unit, University Teaching Hospital of Rangueil, F-31400 Toulouse Cedex 9, France
| | - Vincent Minville
- Critical Care Unit, University Teaching Hospital of Rangueil, F-31400 Toulouse Cedex 9, France
| | - Clément Delmas
- Cardiology Department, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Anne-Sophie Salabert
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Jean François Albucher
- Neurology Department, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Benoit Bataille
- Critical Care Unit, Hôtel Dieu Hospital, F-11100 Narbonne, France
| | - Jean Marc Olivot
- Neurology Department, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Alain Cariou
- Critical Care Unit, APHP, Cochin Hospital, F-75014 Paris, France
| | - Lionel Naccache
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC Lab, F-75013 Paris, France
| | - Pierre Payoux
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Nicholas Schiff
- Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10065, USA
| | - Stein Silva
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
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7
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Hermann B, Candia‐Rivera D, Sharshar T, Gavaret M, Diehl J, Cariou A, Benghanem S. Aberrant brain-heart coupling is associated with the severity of post cardiac arrest brain injury. Ann Clin Transl Neurol 2024; 11:866-882. [PMID: 38243640 PMCID: PMC11021613 DOI: 10.1002/acn3.52000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/24/2023] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE To investigate autonomic nervous system activity measured by brain-heart interactions in comatose patients after cardiac arrest in relation to the severity and prognosis of hypoxic-ischemic brain injury. METHODS Strength and complexity of bidirectional interactions between EEG frequency bands (delta, theta, and alpha) and ECG heart rate variability frequency bands (low frequency, LF and high frequency, HF) were computed using a synthetic data generation model. Primary outcome was the severity of brain injury, assessed by (i) standardized qualitative EEG classification, (ii) somatosensory evoked potentials (N20), and (iii) neuron-specific enolase levels. Secondary outcome was the 3-month neurological status, assessed by the Cerebral Performance Category score [good (1-2) vs. poor outcome (3-4-5)]. RESULTS Between January 2007 and July 2021, 181 patients were admitted to ICU for a resuscitated cardiac arrest. Poor neurological outcome was observed in 134 patients (74%). Qualitative EEG patterns suggesting high severity were associated with decreased LF/HF. Severity of EEG changes were proportional to higher absolute values of brain-to-heart coupling strength (p < 0.02 for all brain-to-heart frequencies) and lower values of alpha-to-HF complexity (p = 0.049). Brain-to-heart coupling strength was significantly higher in patients with bilateral absent N20 and correlated with neuron-specific enolase levels at Day 3. This aberrant brain-to-heart coupling (increased strength and decreased complexity) was also associated with 3-month poor neurological outcome. INTERPRETATION Our results suggest that autonomic dysfunctions may well represent hypoxic-ischemic brain injury post cardiac arrest pathophysiology. These results open avenues for integrative monitoring of autonomic functioning in critical care patients.
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Affiliation(s)
- Bertrand Hermann
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitHEGP Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP.Centre)ParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
| | - Diego Candia‐Rivera
- Sorbonne Université, Paris Brain Institute (ICM), INRIA, CNRS UMR 722, INSERM U1127, AP‐HP Hôpital Pitié‐SalpêtrièreParisFrance
| | - Tarek Sharshar
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- GHU Paris Psychiatrie Neurosciences, Service hospitalo‐universitaire de Neuro‐anesthésie réanimationParisFrance
| | - Martine Gavaret
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- Neurophysiology and Epileptology DepartmentGHU Paris Psychiatrie et NeurosciencesParisFrance
| | - Jean‐Luc Diehl
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitHEGP Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP.Centre)ParisFrance
- Université Paris Cité, INSERM, Innovative Therapies in HaemostasisParisFrance
- Biosurgical Research Lab (Carpentier Foundation)ParisFrance
| | - Alain Cariou
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitCochin Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP‐Centre)ParisFrance
- Paris‐Cardiovascular‐Research‐CenterINSERM U970ParisFrance
| | - Sarah Benghanem
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- Medical Intensive Care UnitCochin Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP‐Centre)ParisFrance
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8
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Jung YH, Lee HY, Lee BK, Choi BK, Kim TH, Kim JW, Kim HC, Kim HJ, Jeung KW. Feasibility of Magnetic Resonance-Based Conductivity Imaging as a Tool to Estimate the Severity of Hypoxic-Ischemic Brain Injury in the First Hours After Cardiac Arrest. Neurocrit Care 2024; 40:538-550. [PMID: 37353670 DOI: 10.1007/s12028-023-01776-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/05/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Early identification of the severity of hypoxic-ischemic brain injury (HIBI) after cardiac arrest can be used to help plan appropriate subsequent therapy. We evaluated whether conductivity of cerebral tissue measured using magnetic resonance-based conductivity imaging (MRCI), which provides contrast derived from the concentration and mobility of ions within the imaged tissue, can reflect the severity of HIBI in the early hours after cardiac arrest. METHODS Fourteen minipigs were resuscitated after 5 min or 12 min of untreated cardiac arrest. MRCI was performed at baseline and at 1 h and 3.5 h after return of spontaneous circulation (ROSC). RESULTS In both groups, the conductivity of cerebral tissue significantly increased at 1 h after ROSC compared with that at baseline (P = 0.031 and 0.016 in the 5-min and 12-min groups, respectively). The increase was greater in the 12-min group, resulting in significantly higher conductivity values in the 12-min group (P = 0.030). At 3.5 h after ROSC, the conductivity of cerebral tissue in the 12-min group remained increased (P = 0.022), whereas that in the 5-min group returned to its baseline level. CONCLUSIONS The conductivity of cerebral tissue was increased in the first hours after ROSC, and the increase was more prominent and lasted longer in the 12-min group than in the 5-min group. Our findings suggest the promising potential of MRCI as a tool to estimate the severity of HIBI in the early hours after cardiac arrest.
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Affiliation(s)
- Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hyoung Youn Lee
- Trauma Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Bup Kyung Choi
- Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Medical Convergence Research Center, Wonkwang University, Iksan, Republic of Korea
| | - Jin Woong Kim
- Department of Radiology, Chosun University Hospital, Gwangju, Republic of Korea
| | - Hyun Chul Kim
- Department of Radiology, Chosun University Hospital, Gwangju, Republic of Korea
| | - Hyung Joong Kim
- Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea.
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea.
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9
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Lin Y, Chen Q, Zhang G, Xie L, Yang X, Zhong H, Xu J, Zhang M. Sodium octanoate alleviates cardiac and cerebral injury after traumatic cardiac arrest in a porcine model. Am J Emerg Med 2024; 78:48-56. [PMID: 38199096 DOI: 10.1016/j.ajem.2023.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/25/2023] [Accepted: 12/31/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Traumatic cardiac arrest (TCA) is a severe condition with a high mortality rate, and patients who survive from TCA face a poor prognosis due to post-resuscitation injury, including cardiac and cerebral injury, which remains a serious challenge. Sodium octanoate has shown protective effects against various diseases. The present study aims to investigate sodium octanoate's protective effects against cardiac and cerebral injury after TCA in a porcine model. METHODS The study included a total of 22 male domestic pigs divided into three groups: Sham group (n = 7), TCA group (n = 7), and sodium octanoate (SO) group (n = 8). Hemorrhage was initiated via the right femoral artery by a blood pump at a rate of 2 ml·kg-1·min-1 to establish TCA model. The Sham group underwent only endotracheal intubation and arteriovenous catheterization, without experiencing the blood loss/cardiac arrest/resuscitation model. At 5 min after resuscitation, the SO group received a continuous sodium octanoate infusion while the TCA group received the same volume of saline. General indicators were monitored, and blood samples were collected at baseline and at different time points after resuscitation. At 24 h after resuscitation, pigs were sacrificed, and heart and brain were obtained for cell apoptosis detection, iron deposition staining, oxidative stress detection, and the expression of ferroptosis-related proteins (ACSL4 and GPX4). RESULTS Sodium octanoate significantly improved mean arterial pressure, cardiac output and ejection fraction induced by TCA. Serum biomarkers of cardiac and cerebral injury were found to increase at all time points after resuscitation, while sodium octanoate significantly reduced their levels. The apoptosis rates of cardiomyocytes and cerebral cortex cells in the SO group were significantly lower than in the TCA group, along with a reduced area of iron deposition staining. The sodium octanoate also reduced oxidative stress and down-regulated ferroptosis which was indicated by protein level alteration of ACSL4 and GPX4. CONCLUSION Our study's findings suggest that early infusion of sodium octanoate significantly alleviates post-resuscitation cardiac and cerebral injury in a porcine model of TCA, possibly through inhibition of cell apoptosis and GPX4-mediated ferroptosis. Therefore, sodium octanoate could be a potential therapeutic strategy for patients with TCA.
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Affiliation(s)
- Yao Lin
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
| | - Qi Chen
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Department of Emergency Medicine, The First People's Hospital of Fuyang Hangzhou, Hangzhou, China
| | - Gongping Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Department of Emergency Medicine, Lishui Municipal Central Hospital, Lishui, China
| | - Lutao Xie
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Department of Emergency Medicine, Lishui Municipal Central Hospital, Lishui, China
| | - Xuelin Yang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Department of Emergency Medicine, Lishui Municipal Central Hospital, Lishui, China
| | - Huiming Zhong
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
| | - Jiefeng Xu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China.
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China.
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Thuccani M, Joelsson S, Lilja L, Strålin A, Nilsson J, Redfors P, Rawshani A, Herlitz J, Lundgren P, Rylander C. The capacity of neurological pupil index to predict the absence of somatosensory evoked potentials after cardiac arrest - An observational study. Resusc Plus 2024; 17:100567. [PMID: 38328749 PMCID: PMC10848026 DOI: 10.1016/j.resplu.2024.100567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 02/09/2024] Open
Abstract
Background In neurologic prognostication of comatose survivors from cardiac arrest, two independent predictors of poor outcome are the loss of the Pupillary light reflex (PLR) and the loss of the N20 response from Somatosensory Evoked potentials (SSEP). The PLR can be quantitatively assessed by pupillometry. Both tests depend on the midbrain, in which a dysfunction reflects a severe hypoxic injury. We reasoned that a certain level of defective PLR would be predictive of a bilaterally absent SSEP N20 response. Method Neurological Pupil index (NPi) from the pupillometry and the SSEP N20 response were registered >48 h after cardiac arrest in comatose survivors. Clinical data were retrospectively analyzed. A receiver operating characteristic curve was used to evaluate the capacity of NPi to predict bilaterally absent SSEP N20 response. An NPi threshold value resulting in <5% false positive rate (FPR) for bilaterally absent N20 response was identified. Results From February 2020 to August 2022, we included 54 patients out of which 49 had conclusive pupillometry and SSEP examinations. The NPi threshold value with FPR < 5% was 3.4, yielding 36% sensitivity (95% CI 18-55) and significantly discriminated between respective groups with preserved and bilaterally absent N20 response to SSEP (p-value <0.01). Conclusion In this limited cohort, NPi < 3.4 in patients remaining comatose >48 hours after cardiac arrest predicted bilateral loss of the SSEP N20 response with a FPR < 5%. If validated in a larger cohort, an NPi threshold may be clinically applied in settings where SSEP is unavailable.
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Affiliation(s)
- Meena Thuccani
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sara Joelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neurophysiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Linus Lilja
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Anaesthesia and Intensive Care, Karlstad Central Hospital, Karlstad, Sweden
| | - Axel Strålin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Josefin Nilsson
- Department of Clinical Neurophysiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Araz Rawshani
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Herlitz
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Prehospen – Centre for Prehospital Research, University of Borås, Sweden
| | - Peter Lundgren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Prehospen – Centre for Prehospital Research, University of Borås, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christian Rylander
- Anaesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Aalberts N, Westhall E, Johnsen B, Hahn K, Kenda M, Cronberg T, Friberg H, Preuß S, Ploner CJ, Storm C, Nee J, Leithner C, Endisch C. Cortical somatosensory evoked potential amplitudes and clinical outcome after cardiac arrest: a retrospective multicenter study. J Neurol 2023; 270:5999-6009. [PMID: 37639017 PMCID: PMC10632270 DOI: 10.1007/s00415-023-11951-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE Bilaterally absent cortical somatosensory evoked potentials (SSEPs) reliably predict poor outcome in comatose cardiac arrest (CA) patients. Cortical SSEP amplitudes are a recent prognostic extension; however, amplitude thresholds, inter-recording, and inter-rater agreement remain uncertain. METHODS In a retrospective multicenter cohort study, we determined cortical SSEP amplitudes of comatose CA patients using a standardized evaluation pathway. We studied inter-recording agreement in repeated SSEPs and inter-rater agreement by four raters independently determining 100 cortical SSEP amplitudes. Primary outcome was assessed using the cerebral performance category (CPC) upon intensive care unit discharge dichotomized into good (CPC 1-3) and poor outcome (CPC 4-5). RESULTS Of 706 patients with SSEPs with median 3 days after CA, 277 (39.2%) had good and 429 (60.8%) poor outcome. Of patients with bilaterally absent cortical SSEPs, one (0.8%) survived with CPC 3 and 130 (99.2%) had poor outcome. Otherwise, the lowest cortical SSEP amplitude in good outcome patients was 0.5 µV. 184 (42.9%) of 429 poor outcome patients had lower cortical SSEP amplitudes. In 106 repeated SSEPs, there were 6 (5.7%) with prognostication-relevant changes in SSEP categories. Following a standardized evaluation pathway, inter-rater agreement was almost perfect with a Fleiss' kappa of 0.88. INTERPRETATION Bilaterally absent and cortical SSEP amplitudes below 0.5 µV predicted poor outcome with high specificity. A standardized evaluation pathway provided high inter-rater and inter-recording agreement. Regain of consciousness in patients with bilaterally absent cortical SSEPs rarely occurs. High-amplitude cortical SSEP amplitudes likely indicate the absence of severe brain injury.
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Affiliation(s)
- Noelle Aalberts
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Birger Johnsen
- Department of Clinical Neurophysiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark
| | - Katrin Hahn
- Department of Neurology, Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Kenda
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- BIH Charité Junior Digital Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Intensive and Perioperative Care, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Sandra Preuß
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jens Nee
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Endisch
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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12
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Czimmeck C, Kenda M, Aalberts N, Endisch C, Ploner CJ, Storm C, Nee J, Streitberger KJ, Leithner C. Confounders for prognostic accuracy of neuron-specific enolase after cardiac arrest: A retrospective cohort study. Resuscitation 2023; 192:109964. [PMID: 37683997 DOI: 10.1016/j.resuscitation.2023.109964] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023]
Abstract
AIM To evaluate neuron-specific enolase (NSE) thresholds for prediction of neurological outcome after cardiac arrest and to analyze the influence of hemolysis and confounders. METHODS Retrospective analysis from a cardiac arrest registry. Determination of NSE serum concentration and hemolysis-index (h-index) 48-96 hours after cardiac arrest. Evaluation of neurological outcome using the Cerebral Performance Category score (CPC) at hospital discharge. Separate analyses considering CPC 1-3 and CPC 1-2 as good neurological outcome. Analysis of specificity and sensitivity for poor and good neurological outcome prediction with and without exclusion of hemolytic samples (h-index larger than 50). RESULTS Among 356 survivors three days after cardiac arrest, hemolysis was detected in 28 samples (7.9%). At a threshold of 60 µg/L, NSE predicted poor neurological outcome (CPC 4-5) in all samples with a specificity of 92% (86-95%) and sensitivity of 73% (66-79%). In non-hemolytic samples, specificity was 94% (89-97%) and sensitivity 70% (62-76%). At a threshold of 100 µg/L, specificity was 98% (95-100%, all samples) and 99% (95-100%, non-hemolytic samples), and sensitivity 58% (51-65%) and 55% (47-63%), respectively. Possible confounders for elevated NSE in patients with good neurological outcome were ECMO, malignancies, blood transfusions and acute brain diseases. Nine patients with NSE below 17 µg/L had CPC 5, all had plausible death causes other than hypoxic-ischemic encephalopathy. CONCLUSIONS NSE concentrations higher than 100 µg/L predicted poor neurological outcome with high specificity. An NSE less than 17 µg/L indicated absence of severe hypoxic-ischemic encephalopathy. Hemolysis and other confounders need to be considered. INSTITUTIONAL PROTOCOL NUMBER The local ethics committee (board name: Ethikkommission der Charité) approved this study by the number: EA2/066/23, approval date: 28th June 2023, study title "'ROSC' - Resuscitation Outcome Study."
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Affiliation(s)
- Constanze Czimmeck
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Martin Kenda
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Noelle Aalberts
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christian Endisch
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christoph J Ploner
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christian Storm
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Charitéplatz 1, 10117 Berlin, Germany
| | - Jens Nee
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Circulatory Arrest Center of Excellence Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Kaspar J Streitberger
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christoph Leithner
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
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13
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Primiani CT, Lee JK, O’Brien CE, Chen MW, Perin J, Kulikowicz E, Santos P, Adams S, Lester B, Rivera-Diaz N, Olberding V, Niedzwiecki MV, Ritzl EK, Habela CW, Liu X, Yang ZJ, Koehler RC, Martin LJ. Hypothermic Protection in Neocortex Is Topographic and Laminar, Seizure Unmitigating, and Partially Rescues Neurons Depleted of RNA Splicing Protein Rbfox3/NeuN in Neonatal Hypoxic-Ischemic Male Piglets. Cells 2023; 12:2454. [PMID: 37887298 PMCID: PMC10605428 DOI: 10.3390/cells12202454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023] Open
Abstract
The effects of hypothermia on neonatal encephalopathy may vary topographically and cytopathologically in the neocortex with manifestations potentially influenced by seizures that alter the severity, distribution, and type of neuropathology. We developed a neonatal piglet survival model of hypoxic-ischemic (HI) encephalopathy and hypothermia (HT) with continuous electroencephalography (cEEG) for seizures. Neonatal male piglets received HI-normothermia (NT), HI-HT, sham-NT, or sham-HT treatments. Randomized unmedicated sham and HI piglets underwent cEEG during recovery. Survival was 2-7 days. Normal and pathological neurons were counted in different neocortical areas, identified by cytoarchitecture and connectomics, using hematoxylin and eosin staining and immunohistochemistry for RNA-binding FOX-1 homolog 3 (Rbfox3/NeuN). Seizure burden was determined. HI-NT piglets had a reduced normal/total neuron ratio and increased ischemic-necrotic/total neuron ratio relative to sham-NT and sham-HT piglets with differing severities in the anterior and posterior motor, somatosensory, and frontal cortices. Neocortical neuropathology was attenuated by HT. HT protection was prominent in layer III of the inferior parietal cortex. Rbfox3 immunoreactivity distinguished cortical neurons as: Rbfox3-positive/normal, Rbfox3-positive/ischemic-necrotic, and Rbfox3-depleted. HI piglets had an increased Rbfox3-depleted/total neuron ratio in layers II and III compared to sham-NT piglets. Neuronal Rbfox3 depletion was partly rescued by HT. Seizure burdens in HI-NT and HI-HT piglets were similar. We conclude that the neonatal HI piglet neocortex has: (1) suprasylvian vulnerability to HI and seizures; (2) a limited neuronal cytopathological repertoire in functionally different regions that engages protective mechanisms with HT; (3) higher seizure burden, insensitive to HT, that is correlated with more panlaminar ischemic-necrotic neurons in the somatosensory cortex; and (4) pathological RNA splicing protein nuclear depletion that is sensitive to HT. This work demonstrates that HT protection of the neocortex in neonatal HI is topographic and laminar, seizure unmitigating, and restores neuronal depletion of RNA splicing factor.
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Affiliation(s)
- Christopher T. Primiani
- Department of Neurology, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Caitlin E. O’Brien
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - May W. Chen
- Department Pediatrics, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA
| | - Jamie Perin
- Department of Biostatistics and Epidemiology, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA
| | - Ewa Kulikowicz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Polan Santos
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Shawn Adams
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Bailey Lester
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Natalia Rivera-Diaz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Valerie Olberding
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Mark V. Niedzwiecki
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Eva K. Ritzl
- Department of Neurology, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA
| | - Christa W. Habela
- Department of Neurology, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA
| | - Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Zeng-Jin Yang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Raymond C. Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
| | - Lee J. Martin
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA; (J.K.L.); (E.K.); (V.O.); (M.V.N.)
- Department of Pathology, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA
- Department of Neuroscience, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA
- The Pathobiology Graduate Training Program, Johns Hopkins University School of Medicine, 558 Ross Building, 720 Rutland Avenue, Baltimore, MD 21205-2196, USA
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14
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Aborode AT, Karra-Aly A, Ogunleye SC, Olorunshola MM, Folorunso TN, Aloba CO, Ogunware AE. Overcoming hurdles: Enhancing post-mortem capabilities for neurological investigations in Africa. AGING BRAIN 2023; 4:100099. [PMID: 37809277 PMCID: PMC10556755 DOI: 10.1016/j.nbas.2023.100099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023] Open
Affiliation(s)
| | - Ayah Karra-Aly
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Seto Charles Ogunleye
- Department of Comparative Biomedical Sciences, College of Veterinary Medicine, Mississippi State University, 39760 MS, USA
| | | | | | | | - Adedayo Emmanuel Ogunware
- Department of Neuroscience, Development and Regenerative Biology, The University of Texas at San Antonio, TX, USA
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15
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Horn J, Admiraal M, Hofmeijer J. Diagnosis and management of seizures and myoclonus after cardiac arrest. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:525-531. [PMID: 37486703 DOI: 10.1093/ehjacc/zuad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Janneke Horn
- Department of Intensive care Medicine, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Neurosciences Institute, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marjolein Admiraal
- Neurosciences Institute, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Neurology and Clinical Neurophysiology, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Technical Medical Center, Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
- Department of Neurology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
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16
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Kondziella D. Neuroprognostication after cardiac arrest: what the cardiologist should know. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:550-558. [PMID: 36866627 DOI: 10.1093/ehjacc/zuad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/04/2023]
Abstract
Two aspects are a key to mastering prognostication of comatose cardiac arrest survivors: a detailed knowledge about the clinical trajectories of consciousness recovery (or lack thereof) and the ability to correctly interpret the results of multimodal investigations, which include clinical examination, electroencephalography, neuroimaging, evoked potentials, and blood biomarkers. While the very good and the very poor ends of the clinical spectrum typically do not pose diagnostic challenges, the intermediate 'grey zone' of post-cardiac arrest encephalopathy requires cautious interpretation of the available information and sufficiently long clinical observation. Late recovery of coma patients with initially ambiguous diagnostic results is increasingly reported, as are unresponsive patients with various forms of residual consciousness, including so-called cognitive motor dissociation, rendering prognostication of post-anoxic coma highly complex. The aim of this paper is to provide busy clinicians with a high-yield, concise overview of neuroprognostication after cardiac arrest, emphasizing notable developments in the field since 2020.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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17
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Tziakouri A, Novy J, Ben-Hamouda N, Rossetti AO. Relationship between serum neuron-specific enolase and EEG after cardiac arrest: A reappraisal. Clin Neurophysiol 2023; 151:100-106. [PMID: 37236128 DOI: 10.1016/j.clinph.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/05/2023] [Accepted: 05/01/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE Electroencephalogram (EEG) and serum neuron specific enolase (NSE) are frequently used prognosticators after cardiac arrest (CA). This study explored the association between NSE and EEG, considering the role of EEG timing, its background continuity, reactivity, occurrence of epileptiform discharges, and pre-defined malignancy degree. METHODS Retrospective analysis including 445 consecutive adults from a prospective registry, surviving the first 24 hours after CA and undergoing multimodal evaluation. EEG were interpreted blinded to NSE results. RESULTS Higher NSE was associated with poor EEG prognosticators, such as increasing malignancy, repetitive epileptiform discharges and lack of background reactivity, independently of EEG timing (including sedation and temperature). When stratified for background continuity, NSE was higher with repetitive epileptiform discharges, except in the case of suppressed EEGs. This relationship showed some variation according to the recording time. CONCLUSIONS Neuronal injury after CA, reflected by NSE, correlates with several EEG features: increasing EEG malignancy, lack of background reactivity, and presence of repetitive epileptiform discharges. The correlation between epileptiform discharges and NSE is influenced by underlying EEG background and timing. SIGNIFICANCE This study, describing the complex interplay between serum NSE and epileptiform features, suggests that epileptiform discharges reflect neuronal injury particularly in non-suppressed EEG.
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Affiliation(s)
- Andria Tziakouri
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Novy
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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18
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McDevitt WM, Farley M, Martin-Lamb D, Jones TJ, Morris KP, Seri S, Scholefield BR. Feasibility of non-invasive neuro-monitoring during extracorporeal membrane oxygenation in children. Perfusion 2023; 38:547-556. [PMID: 35212252 DOI: 10.1177/02676591211066804] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Detection of neurological complications during extracorporeal membrane oxygenation (ECMO) may be enhanced with non-invasive neuro-monitoring. We investigated the feasibility of non-invasive neuro-monitoring in a paediatric intensive care (PIC) setting. METHODS In a single centre, prospective cohort study we assessed feasibility of recruitment, and neuro-monitoring via somatosensory evoked potentials (SSEP), electroencephalography (EEG) and near infrared spectroscopy (NIRS) during venoarterial (VA) ECMO in paediatric patients (0-15 years). Measures were obtained within 24h of cannulation, during an intermediate period, and finally at decannulation or echo stress testing. SSEP/EEG/NIRS measures were correlated with neuro-radiology findings, and clinical outcome assessed via the Pediatric cerebral performance category (PCPC) scale 30 days post ECMO cannulation. RESULTS We recruited 14/20 (70%) eligible patients (median age: 9 months; IQR:4-54, 57% male) over an 18-month period, resulting in a total of 42 possible SSEP/EEG/NIRS measurements. Of these, 32/42 (76%) were completed. Missed recordings were due to lack of access/consent within 24 h of cannulation (5/42, 12%) or PIC death/discharge (5/42, 12%). In each patient, the majority of SSEP (8/14, 57%), EEG (8/14, 57%) and NIRS (11/14, 79%) test results were within normal limits. All patients with abnormal neuroradiology (4/10, 40%), and 6/7 (86%) with poor outcome (PCPC ≥4) developed indirect SSEP, EEG or NIRS measures of neurological complications prior to decannulation. No study-related adverse events or neuro-monitoring data interpreting issues were experienced. CONCLUSION Non-invasive neuro-monitoring (SSEP/EEG/NIRS) during ECMO is feasible and may provide early indication of neurological complications in this high-risk population.
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Affiliation(s)
- William M McDevitt
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK
| | - Margaret Farley
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK
| | - Darren Martin-Lamb
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK
| | - Timothy J Jones
- Department of Cardiac Surgery, 156630Birmingham Children's Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Kevin P Morris
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Stefano Seri
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK.,Aston Brain Centre, School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK.,Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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19
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Status Epilepticus. Crit Care Clin 2023; 39:87-102. [DOI: 10.1016/j.ccc.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Ploch M, Ahmed T, Reyes S, Irizarry-Caro JA, Fossas-Espinosa JE, Shoar S, Amatullah A, Jogimahanti A, Antonioli M, Iliescu CA, Balan P, Naeini PS, Madjid M. Determinants of change in code status among patients with cardiopulmonary arrest admitted to the intensive care unit. Resuscitation 2022; 181:190-196. [PMID: 36174763 DOI: 10.1016/j.resuscitation.2022.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with cardiopulmonary arrest often have a poor prognosis, prompting discussion with families about code status. The impact of socioeconomic factors, demographics, medical comorbidities and medical interventions on code status changes is not well understood. METHODS This retrospective study included adult patients presenting with cardiac arrest to the intensive care unit of a hospital group between 5/1/2010-5/1/2020. We extracted chart data on socioeconomic factors, demographics, and medical comorbidities. RESULTS We identified 1,254 patients, of which 57.5% were males. Age was different across the groups with (61.2 ± 15.5 years) and without (61.2 ± 15.5 years) code status change (p= <0.0001). Code status was changed in 583 patients (46.5%). Among patients with code status change, the highest prevalence was White patients (34.8%), followed by African Americans (30.9%), and Hispanics (25.4%). Compared to patients who did not have a code status change, those with a change in code status were older (66.7 ± 14.8 years vs 61.2 ± 15.5 years). They were also more likely to receive vasopressor/inotropic support (74.6% vs 58.5%), and broad-spectrum antibiotics (70.3% vs 57.7%). Insurance status, ethnicity, religion, education, and salary did not lead to statistically significant changes in code status. CONCLUSIONS In patients with cardiopulmonary arrest, code status change was more likely to be influenced by the presence of medical comorbidities and medical interventions during hospitalization rather than by socioeconomic factors.
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Affiliation(s)
- Michelle Ploch
- Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Talha Ahmed
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States; Heart and Vascular Institute, Memorial Hermann Hospital, Houston, TX, United States
| | - Stephan Reyes
- Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jorge A Irizarry-Caro
- Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jose E Fossas-Espinosa
- Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Saeed Shoar
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States; Heart and Vascular Institute, Memorial Hermann Hospital, Houston, TX, United States
| | - Atia Amatullah
- Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Arjun Jogimahanti
- Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Matthew Antonioli
- Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Cesar A Iliescu
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Prakash Balan
- Department of Cardiology, Banner University Medical Center, University of Arizona College of Medicine, Phoenix, AZ, United States
| | - Payam Safavi Naeini
- Center for Cardiac Arrhythmias and Electrophysiology, Texas Heart Institute, Houston, TX, United States
| | - Mohammad Madjid
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States; Heart and Vascular Institute, Memorial Hermann Hospital, Houston, TX, United States; Division of Cardiology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, United States.
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21
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Mertens M, King OC, van Putten MJAM, Boenink M. Can we learn from hidden mistakes? Self-fulfilling prophecy and responsible neuroprognostic innovation. JOURNAL OF MEDICAL ETHICS 2022; 48:922-928. [PMID: 34253620 PMCID: PMC9626909 DOI: 10.1136/medethics-2020-106636] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 05/22/2021] [Indexed: 05/24/2023]
Abstract
A self-fulfilling prophecy (SFP) in neuroprognostication occurs when a patient in coma is predicted to have a poor outcome, and life-sustaining treatment is withdrawn on the basis of that prediction, thus directly bringing about a poor outcome (viz. death) for that patient. In contrast to the predominant emphasis in the bioethics literature, we look beyond the moral issues raised by the possibility that an erroneous prediction might lead to the death of a patient who otherwise would have lived. Instead, we focus on the problematic epistemic consequences of neuroprognostic SFPs in settings where research and practice intersect. When this sort of SFP occurs, the problem is that physicians and researchers are never in a position to notice whether their original prognosis was correct or incorrect, since the patient dies anyway. Thus, SFPs keep us from discerning false positives from true positives, inhibiting proper assessment of novel prognostic tests. This epistemic problem of SFPs thus impedes learning, but ethical obligations of patient care make it difficult to avoid SFPs. We then show how the impediment to catching false positive indicators of poor outcome distorts research on novel techniques for neuroprognostication, allowing biases to persist in prognostic tests. We finally highlight a particular risk that a precautionary bias towards early withdrawal of life-sustaining treatment may be amplified. We conclude with guidelines about how researchers can mitigate the epistemic problems of SFPs, to achieve more responsible innovation of neuroprognostication for patients in coma.
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Affiliation(s)
- Mayli Mertens
- Center for Medical Science and Technology Studies, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Philosophy, University of Twente, Enschede, Overijssel, The Netherlands
| | - Owen C King
- Department of Philosophy, University of Twente, Enschede, Overijssel, The Netherlands
| | - Michel J A M van Putten
- MIRA-Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Overijssel, The Netherlands
- Department of Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, Overijssel, The Netherlands
| | - Marianne Boenink
- Department of Philosophy, University of Twente, Enschede, Overijssel, The Netherlands
- Department IQ Healthcare, RadboudUMC - Radboud University, Nijmegen, Gelderland, the Netherlands
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22
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Coppler PJ, Flickinger KL, Darby JM, Doshi A, Guyette FX, Faro J, Callaway CW, Elmer J. Early risk stratification for progression to death by neurological criteria following out-of-hospital cardiac arrest. Resuscitation 2022; 179:248-255. [PMID: 35914657 DOI: 10.1016/j.resuscitation.2022.07.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/27/2022] [Accepted: 07/22/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Some patients resuscitated from out-of-hospital cardiac arrest (OHCA) progress to death by neurological criteria (DNC). We hypothesized that initial brain imaging, electroencephalography (EEG), and arrest characteristics predict progression to DNC. METHODS We identified comatose OHCA patients from January 2010 to February 2020 treated at a single quaternary care facility in Western Pennsylvania. We abstracted demographics and arrest characteristics; Pittsburgh Cardiac Arrest Category, initial motor exam and pupillary light reflex; initial brain computed tomography (CT) grey-to-white ratio (GWR), sulcal or basal cistern effacement; initial EEG background and suppression ratio. We used two modeling approaches: fast and frugal tree (FFT) analysis to create an interpretable clinical risk stratification tool and ridge regression for comparison. We used bootstrapping to randomly partition cases into 80% training and 20% test sets and evaluated test set sensitivity and specificity. RESULTS We included 1,569 patients, of whom 147 (9%) had diagnosed DNC. Across bootstrap samples, >99% of FFTs included three predictors: sulcal effacement, and in cases without sulcal effacement, the combination of EEG background suppression and GWR ≤ 1.23. This tree had mean sensitivity and specificity of 87% and 81%. Ridge regression with all available predictors had mean sensitivity 91 % and mean specificity 83%. Subjects falsely predicted as likely to progress to DNC generally died of rearrest or withdrawal of life sustaining therapies due to poor neurological prognosis. Two of these cases awakened from coma during the index hospitalization. CONCLUSIONS Sulcal effacement on presenting brain CT or EEG suppression with GWR ≤ 1.23 predict progression to DNC after OHCA.
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Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | | | - Joseph M Darby
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ankur Doshi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John Faro
- Department of Family Medicine, Soin Medical Center - Kettering Health Network, Beavercreek, OH, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
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23
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Clinical Efficacy of Subhypothermia in the Treatment of Neonatal Hypoxic-Ischemic Encephalopathy Combined with Myocardial Damage. ADSORPT SCI TECHNOL 2022. [DOI: 10.1155/2022/2465490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective. To investigate the efficacy of subhypothermia in the treatment of neonatal hypoxic-ischemic encephalopathy (HIE) combined with myocardial damage. Methods. 136 children with HIE and myocardial damage admitted to our hospital from October 2019 to October 2021 were included in the study and were divided into study group and control group of 68 cases each according to the random number table method. The control group was given conventional treatment, and the study group was treated with subhypothermia therapy on top of the control group. Comparing the effects of treatment between the two groups. The serum levels of S-100β protein, Tau protein, neuron-specific enolase (NSE), creatine kinase (CK), creatine kinase isoenzyme MB (CK-MB), lactate dehydrogenase (LDH), alpha-hydroxybutyrate dehydrogenase (ɑ-HBDH), myoglobin (Myo), cardiac trophic factor-1 (CT-1), cardiac troponin I (cTnI), superoxide dismutase (SOD), reactive oxygen species (ROS), glutathione peroxidase (GSH-Px), interleukin-1β (IL-1β), interleukin-8 (IL-8), and tumor necrosis factor-ɑ (TNF-ɑ) were measured in both groups before and after treatment, respectively. Results. The total effective rate was higher in the study group (88.24%) than in the control group (72.06%) (
). After treatment, the serum levels of S-100β protein, Tau protein, NSE, CK, CK-MB, LDH, ɑ-HBDH, Myo, CT-1, cTnI, ROS, IL-1β, IL-8, and TNF-ɑ were reduced in both groups, and the study group was lower than the control group (
). The serum levels of SOD and GSH-Px were higher in both groups after treatment than before treatment and were higher in the study group than in the control group (
). Conclusion. Subhypothermia treatment of children with HIE combined with myocardial injury can further improve the hypoxic-ischemic state; reduce myocardial damage, oxidative stress, and inflammatory response; and has a good overall efficacy.
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Liu S, Gao Q, Guan M, Chen Y, Cheng S, Yang L, Meng W, Lu C, Li B. Effectiveness of transcranial direct current stimulation over dorsolateral prefrontal cortex in patients with prolonged disorders of consciousness: A systematic review and meta-analysis. Front Neurol 2022; 13:998953. [PMID: 36226076 PMCID: PMC9549167 DOI: 10.3389/fneur.2022.998953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background Transcranial direct current stimulation (tDCS) has been widely studied for treatment of patients with prolonged disorders of consciousness (PDOC). The dorsolateral prefrontal cortex (DLPFC) is a hot target for intervention, but some controversies remain. Purpose This review aimed to systematically investigate the therapeutic effects of DLPFC-anodal-tDCS for patients with PDOC through a meta-analysis approach. Data sources Searches for relevant articles available in English were conducted using EMBASE, Medline, Web of Science, EBSCO, and Cochrane Central Register of Controlled Trials from inception until March 26, 2022. Study selection All randomized parallel or cross-over controlled trials comparing the effect of intervention with active-tDCS and Sham-tDCS on Coma Recovery Scale Revised (CRS-R) score in individuals with PDOC were included. Data extraction Two authors independently extracted data, assessed the methodological quality, and rated each study. Data synthesis Ten randomized parallel or cross-over controlled trials were eligible for systematic review, and eight of the studies involving 165 individuals were identified as eligible for meta-analysis. Compared with Sham-tDCS, the use of anode-tDCS over DLPFC improved the CRS-R score (SMD = 0.71; 95% CI: 0.47–0.95, I2 = 10%). Patients with PDOC classified as MCS and clinically diagnosed as CVA or TBI may benefit from anode-tDCS. Limitations Failure to evaluate the long-term effects and lack of quantitative analysis of neurological examination are the main limitations for the application of anode-tDCS. Conclusions Anodal-tDCS over the left DLPFC may be advantageous to the recovery of patients with MCS and clinically diagnosed with CVA or TBI. There is a lack of evidence to support the duration of the disease course will limit the performance of the treatment. Further studies are needed to explore the diversity of stimulation targets and help to improve the mesocircuit model. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=279391, identifier: CRD42022279391.
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Arciniegas-Villanueva AV, Fernández-Diaz EM, Gonzalez-Garcìa E, Sancho-Pelluz J, Mansilla-Lozano D, Segura T. Functional and Prognostic Assessment in Comatose Patients: A Study Using Somatosensory Evoked Potentials. Front Hum Neurosci 2022; 16:904455. [PMID: 35860398 PMCID: PMC9289095 DOI: 10.3389/fnhum.2022.904455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Aim The functional prognosis of patients after coma following either cardiac arrest (CA) or acute structural brain injury (ABI) is often uncertain. These patients are associated with high mortality and disability. N20 and N70 somatosensory evoked potentials (SSEP) are used to predict prognosis. We evaluated the utility of SSEP (N20–N70) as an early indicator of long-term prognosis in these patients. Methods This was a retrospective cohort study of patients (n = 120) admitted to the intensive care unit (ICU) with a diagnosis of coma after CA (n = 60) or ABI (n = 60). An SSEP study was performed, including N20 and N70 at 24–72 h, after coma onset. Functional recovery was assessed 6–12 months later using the modified Glasgow scale (mGS). The study was approved by our local research ethics committee. Results In the CA and ABI groups, the absence of N20 (36% of CA patients and 41% of ABI patients; specificity = 100%) or N70 (68% of CA patients and 78% of ABI patients) was a strong indicator of poor outcome. Conversely, the presence of N70 was an indicator of a good outcome (AC: specificity = 84.2%, sensitivity = 92.7%; ABI: specificity = 64.2% sensitivity = 91.3%). Conclusion Somatosensory evoked potentials are useful early prognostic markers with high specificity (N20) and sensitivity (N70). Moreover, N70 has additional potential value for improving the prediction of good long-term functional outcomes. Clinical Trial Registration: [https://clinicaltrials.gov/], identifier [2018/01/001].
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Affiliation(s)
- Andrea Victoria Arciniegas-Villanueva
- Escuela de Doctorado, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
- Neurophysiology Service, Hospital de Manises, Valencia, Spain
- *Correspondence: Andrea Victoria Arciniegas-Villanueva,
| | | | | | - Javier Sancho-Pelluz
- Neurobiología y Neurofisiología, Facultad de Medicina y Ciencias de la Salud, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
| | | | - Tomás Segura
- Neurology Service, Hospital General Universitario de Albacete, Albacete, Spain
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Arciniegas-Villanueva AV, Fernández-Diaz EM, González-García E, Sancho-Pelluz J, Mansilla-Lozano D, Diaz-Maroto MI, Segura T. The Added Value of Somatosensory Potential N70 in Neurological Prognosis After Coma by Acute Brain Structural Injury: A Retrospective Study. Ann Neurosci 2022; 29:129-136. [DOI: 10.1177/09727531221100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Coma after acute brain structural injury (ABI) are associated with high mortality and disability. Somatosensory evoked potentials (SSEP) N20 and N70 are used to predict prognosis. Purpose: We assessed the utility of SSEP (N20-N70) as an early indicator of long-term functional prognosis in these patients. Methods: We conducted a retrospective cohort study of patients admitted to the intensive care unit (ICU) with a diagnosis of coma after ABI (n=60). An SSEP study including N20 and N70 was performed 24–72 hours after coma onset. Functional recovery was evaluated 6 to 12 months later using the Modified Glasgow Scale (mGS). The study was approved by our local research ethics committee. Results: The absence of N20 (41% specificity=100%) or N70 (78%) was a strong indicator of a poor outcome. In contrast, the presence of N70 was an indicator of a good outcome (specificity=64.2% sensitivity=91.3%). Conclusion: SSEP N20 and N70 are useful early prognostic markers with high specificity (N20) and sensitivity (N70). N70 has potential additional value for improving the prediction of good functional outcomes in the long term.
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Affiliation(s)
- Andrea Victoria Arciniegas-Villanueva
- Neurophysiology Service, Hospital de Manises, Valencia, Spain
- Escuela de Doctorado, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
| | | | | | - Javier Sancho-Pelluz
- Neurobiología y Neurofisiología, Facultad de Medicina y Ciencias de la Salud, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
| | | | | | - Tomás Segura
- Neurology Service, Hospital General Universitario de Albacete, Albacete, Spain
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Grindegård L, Cronberg T, Backman S, Blennow K, Dankiewicz J, Friberg H, Hassager C, Horn J, Kjaer TW, Kjaergaard J, Kuiper M, Mattsson-Carlgren N, Nielsen N, van Rootselaar AF, Rossetti AO, Stammet P, Ullén S, Zetterberg H, Westhall E, Moseby-Knappe M. Association Between EEG Patterns and Serum Neurofilament Light After Cardiac Arrest. Neurology 2022; 98:e2487-e2498. [PMID: 35470143 PMCID: PMC9231840 DOI: 10.1212/wnl.0000000000200335] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 02/21/2022] [Indexed: 01/09/2023] Open
Abstract
Background and Objectives EEG is widely used for prediction of neurologic outcome after cardiac arrest. To better understand the relationship between EEG and neuronal injury, we explored the association between EEG and neurofilament light (NfL) as a marker of neuroaxonal injury, evaluated whether highly malignant EEG patterns are reflected by high NfL levels, and explored the association of EEG backgrounds and EEG discharges with NfL. Methods We performed a post hoc analysis of the Target Temperature Management After Out-of-Hospital Cardiac Arrest trial. Routine EEGs were prospectively performed after the temperature intervention ≥36 hours postarrest. Patients who awoke or died prior to 36 hours postarrest were excluded. EEG experts blinded to clinical information classified EEG background, amount of discharges, and highly malignant EEG patterns according to the standardized American Clinical Neurophysiology Society terminology. Prospectively collected serum samples were analyzed for NfL after trial completion. The highest available concentration at 48 or 72 hours postarrest was used. Results A total of 262/939 patients with EEG and NfL data were included. Patients with highly malignant EEG patterns had 2.9 times higher NfL levels than patients with malignant patterns and NfL levels were 13 times higher in patients with malignant patterns than those with benign patterns (95% CI 1.4–6.1 and 6.5–26.2, respectively; effect size 0.47; p < 0.001). Both background and the amount of discharges were independently strongly associated with NfL levels (p < 0.001). The EEG background had a stronger association with NfL levels than EEG discharges (R2 = 0.30 and R2 = 0.10, respectively). NfL levels in patients with a continuous background were lower than for any other background (95% CI for discontinuous, burst-suppression, and suppression, respectively: 2.26–18.06, 3.91–41.71, and 5.74–41.74; effect size 0.30; p < 0.001 for all). NfL levels did not differ between suppression and burst suppression. Superimposed discharges were only associated with higher NfL levels if the EEG background was continuous. Discussion Benign, malignant, and highly malignant EEG patterns reflect the extent of brain injury as measured by NfL in serum. The extent of brain injury is more strongly related to the EEG background than superimposed discharges. Combining EEG and NfL may be useful to better identify patients misclassified by single methods. Trial Registration Information ClinicalTrials.gov NCT01020916.
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Affiliation(s)
- Linnéa Grindegård
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China.
| | - Tobias Cronberg
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Sofia Backman
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Kaj Blennow
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Josef Dankiewicz
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Hans Friberg
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Christian Hassager
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Janneke Horn
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Troels W Kjaer
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Jesper Kjaergaard
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Michael Kuiper
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Niklas Mattsson-Carlgren
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Niklas Nielsen
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Anne-Fleur van Rootselaar
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Andrea O Rossetti
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Pascal Stammet
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Susann Ullén
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Henrik Zetterberg
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Erik Westhall
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Marion Moseby-Knappe
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
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Coppler PJ, Elmer J. Novel pupillary assessment in post anoxic coma. Resuscitation 2022; 176:66-67. [PMID: 35654227 DOI: 10.1016/j.resuscitation.2022.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 12/22/2022]
Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
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Chen J, Dai C, Yang Y, Wang Y, Zeng R, Li B, Liu Q. The association between anion gap and in-hospital mortality of post-cardiac arrest patients: a retrospective study. Sci Rep 2022; 12:7405. [PMID: 35524151 PMCID: PMC9076652 DOI: 10.1038/s41598-022-11081-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/31/2022] [Indexed: 01/24/2023] Open
Abstract
We aimed to determine the association between anion gap and in-hospital mortality in post-cardiac arrest (CA) patients. Extracted the data of patients diagnosed with CA from MIMIC-IV database. Generalized additive model (GAM), Cox regression and Kaplan–Meier survival analysis were used to demonstrate the association between AG levels and in-hospital mortality. ROC curve analysis for assessing the discrimination of AG for predicting in-hospital mortality. Totally, 1724 eligible subjects were included in our study finally. 936 patients (551 males and 385 females) died in hospital, with the prevalence of in-hospital mortality was 54.3%. The result of the Kaplan–Meier analysis showed that the higher value of AG had significant lower survival possibility during the hospitalization compared with the lower-value of AG patients. In the crude Cox regression model, high-level of AG subjects was associated with significant higher HR compared with low-level of AG subjects. After adjusted the vital signs data, laboratory data, and treatment, high-level of AG (group Q3 and group Q4) were also associated with increased risk of in-hospital mortality compared with low-level of AG group, 1.52 (95% Cl 1.17–1.85; P < 0.001), 1.64 (95% Cl 1.21–2.08; P < 0.001), respectively. The ROC curve indicated that AG has acceptable discrimination for predicting in-hospital mortality. The AUC value was found to be 0.671 (95% CI 0.646–0.698). Higher AG levels was associated with poor prognosis in post-CA patients. AG is a predictor for predicting in-hospital mortality of CA, and could help refine risk stratification.
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Affiliation(s)
- Jun Chen
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310000, Zhejiang, China
| | - Chuxing Dai
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310000, Zhejiang, China
| | - Yang Yang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310000, Zhejiang, China
| | - Yimin Wang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310000, Zhejiang, China
| | - Rui Zeng
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310000, Zhejiang, China
| | - Bo Li
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qiang Liu
- The Third Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, 310000, Zhejiang, China. .,The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310000, Zhejiang, China.
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30
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Prognosis After Cardiac Arrest: The Additional Value of DWI and FLAIR to EEG. Neurocrit Care 2022; 37:302-313. [DOI: 10.1007/s12028-022-01498-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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Snider SB, Fischer D, McKeown ME, Cohen AL, Schaper FLWVJ, Amorim E, Fox MD, Scirica B, Bevers MB, Lee JW. Regional Distribution of Brain Injury After Cardiac Arrest: Clinical and Electrographic Correlates. Neurology 2022; 98:e1238-e1247. [PMID: 35017304 PMCID: PMC8967331 DOI: 10.1212/wnl.0000000000013301] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 12/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Disorders of consciousness, EEG background suppression, and epileptic seizures are associated with poor outcome after cardiac arrest. Our objective was to identify the distribution of diffusion MRI-measured anoxic brain injury after cardiac arrest and to define the regional correlates of disorders of consciousness, EEG background suppression, and seizures. METHODS We analyzed patients from a single-center database of unresponsive patients who underwent diffusion MRI after cardiac arrest (n = 204). We classified each patient according to recovery of consciousness (command following) before discharge, the most continuous EEG background (burst suppression vs continuous), and the presence or absence of seizures. Anoxic brain injury was measured with the apparent diffusion coefficient (ADC) signal. We identified ADC abnormalities relative to controls without cardiac arrest (n = 48) and used voxel lesion symptom mapping to identify regional associations with disorders of consciousness, EEG background suppression, and seizures. We then used a bootstrapped lasso regression procedure to identify robust, multivariate regional associations with each outcome variable. Last, using area under receiver operating characteristic curves, we then compared the classification ability of the strongest regional associations to that of brain-wide summary measures. RESULTS Compared to controls, patients with cardiac arrest demonstrated ADC signal reduction that was most significant in the occipital lobes. Disorders of consciousness were associated with reduced ADC most prominently in the occipital lobes but also in deep structures. Regional injury more accurately classified patients with disorders of consciousness than whole-brain injury. Background suppression mapped to a similar set of brain regions, but regional injury could no better classify patients than whole-brain measures. Seizures were less common in patients with more severe anoxic injury, particularly in those with injury to the lateral temporal white matter. DISCUSSION Anoxic brain injury was most prevalent in posterior cerebral regions, and this regional pattern of injury was a better predictor of disorders of consciousness than whole-brain injury measures. EEG background suppression lacked a specific regional association, but patients with injury to the temporal lobe were less likely to have seizures. Regional patterns of anoxic brain injury are relevant to the clinical and electrographic sequelae of cardiac arrest and may hold importance for prognosis. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that disorders of consciousness after cardiac arrest are associated with widely lower ADC values on diffusion MRI and are most strongly associated with reductions in occipital ADC.
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Affiliation(s)
- Samuel B Snider
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - David Fischer
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Morgan E McKeown
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alexander Li Cohen
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Frederic L W V J Schaper
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Edilberto Amorim
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael D Fox
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Benjamin Scirica
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Matthew B Bevers
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jong Woo Lee
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Benghanem S, Nguyen LS, Gavaret M, Mira JP, Pène F, Charpentier J, Marchi A, Cariou A. SSEP N20 and P25 amplitudes predict poor and good neurologic outcomes after cardiac arrest. Ann Intensive Care 2022; 12:25. [PMID: 35290522 PMCID: PMC8924339 DOI: 10.1186/s13613-022-00999-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/27/2022] [Indexed: 11/18/2022] Open
Abstract
Background To assess in comatose patients after cardiac arrest (CA) if amplitudes of two somatosensory evoked potentials (SSEP) responses, namely, N20-baseline (N20-b) and N20–P25, are predictive of neurological outcome. Methods Monocentric prospective study in a tertiary cardiac center between Nov 2019 and July-2021. All patients comatose at 72 h after CA with at least one SSEP recorded were included. The N20-b and N20–P25 amplitudes were automatically measured in microvolts (µV), along with other recommended prognostic markers (status myoclonus, neuron-specific enolase levels at 2 and 3 days, and EEG pattern). We assessed the predictive value of SSEP for neurologic outcome using the best Cerebral Performance Categories (CPC1 or 2 as good outcome) at 3 months (main endpoint) and 6 months (secondary endpoint). Specificity and sensitivity of different thresholds of SSEP amplitudes, alone or in combination with other prognostic markers, were calculated. Results Among 82 patients, a poor outcome (CPC 3–5) was observed in 78% of patients at 3 months. The median time to SSEP recording was 3(2–4) days after CA, with a pattern “bilaterally absent” in 19 patients, “unilaterally present” in 4, and “bilaterally present” in 59 patients. The median N20-b amplitudes were different between patients with poor and good outcomes, i.e., 0.93 [0–2.05]µV vs. 1.56 [1.24–2.75]µV, respectively (p < 0.0001), as the median N20–P25 amplitudes (0.57 [0–1.43]µV in poor outcome vs. 2.64 [1.39–3.80]µV in good outcome patients p < 0.0001). An N20-b > 2 µV predicted good outcome with a specificity of 73% and a moderate sensitivity of 39%, although an N20–P25 > 3.2 µV was 93% specific and only 30% sensitive. A low voltage N20-b < 0.88 µV and N20–P25 < 1 µV predicted poor outcome with a high specificity (sp = 94% and 93%, respectively) and a moderate sensitivity (se = 50% and 66%). Association of “bilaterally absent or low voltage SSEP” patterns increased the sensitivity significantly as compared to “bilaterally absent” SSEP alone (se = 58 vs. 30%, p = 0.002) for prediction of poor outcome. Conclusion In comatose patient after CA, both N20-b and N20–P25 amplitudes could predict both good and poor outcomes with high specificity but low to moderate sensitivity. Our results suggest that caution is needed regarding SSEP amplitudes in clinical routine, and that these indicators should be used in a multimodal approach for prognostication after cardiac arrest. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00999-6.
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Affiliation(s)
- Sarah Benghanem
- Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Medical School, University of Paris, Paris, France. .,After ROSC Network, Paris, France. .,INSERM 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Sainte Anne Hospital, Paris, France.
| | - Lee S Nguyen
- CMC Ambroise Paré, Research and Innovation, Neuilly-sur-Seine, France
| | - Martine Gavaret
- Medical School, University of Paris, Paris, France.,Neurophysiology Department, GHU Psychiatrie et Neurosciences, Sainte Anne Hospital, Paris, France.,INSERM 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Sainte Anne Hospital, Paris, France
| | - Jean-Paul Mira
- Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Medical School, University of Paris, Paris, France
| | - Frédéric Pène
- Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Medical School, University of Paris, Paris, France
| | - Julien Charpentier
- Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Angela Marchi
- Medical School, University of Paris, Paris, France.,Neurophysiology Department, GHU Psychiatrie et Neurosciences, Sainte Anne Hospital, Paris, France.,INSERM 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Sainte Anne Hospital, Paris, France
| | - Alain Cariou
- Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Medical School, University of Paris, Paris, France.,After ROSC Network, Paris, France.,Paris-Cardiovascular-Research-Center (Sudden-Death-Expertise-Center), INSERM U970, Paris, France
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Sandroni C, D'Arrigo S, Cacciola S, Hoedemaekers CWE, Westhall E, Kamps MJA, Taccone FS, Poole D, Meijer FJA, Antonelli M, Hirsch KG, Soar J, Nolan JP, Cronberg T. Prediction of good neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 2022; 48:389-413. [PMID: 35244745 PMCID: PMC8940794 DOI: 10.1007/s00134-022-06618-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE To assess the ability of clinical examination, blood biomarkers, electrophysiology or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict good neurological outcome, defined as no, mild, or moderate disability (CPC 1-2 or mRS 0-3) at discharge from intensive care unit or later, in comatose adult survivors from cardiac arrest (CA). METHODS PubMed, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews were searched. Sensitivity and specificity for good outcome were calculated for each predictor. The risk of bias was assessed using the QUIPS tool. RESULTS A total of 37 studies were included. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. A withdrawal or localisation motor response to pain immediately or at 72-96 h after ROSC, normal blood values of neuron-specific enolase (NSE) at 24 h-72 h after ROSC, a short-latency somatosensory evoked potentials (SSEPs) N20 wave amplitude > 4 µV or a continuous background without discharges on electroencephalogram (EEG) within 72 h from ROSC, and absent diffusion restriction in the cortex or deep grey matter on MRI on days 2-7 after ROSC predicted good neurological outcome with more than 80% specificity and a sensitivity above 40% in most studies. Most studies had moderate or high risk of bias. CONCLUSIONS In comatose cardiac arrest survivors, clinical, biomarker, electrophysiology, and imaging studies identified patients destined to a good neurological outcome with high specificity within the first week after cardiac arrest (CA).
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sonia D'Arrigo
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Sofia Cacciola
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Marlijn J A Kamps
- Intensive Care Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniele Poole
- Department of Anaesthesiology and Intensive Care, San Martino Hospital, Belluno, Italy
| | - Frederick J A Meijer
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Karen G Hirsch
- Department of Neurology, Stanford University, Stanford, USA
| | - Jasmeet Soar
- Critical Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
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Elmer J, Liu C, Pease M, Arefan D, Coppler PJ, Flickinger K, Mettenburg JM, Baldwin ME, Barot N, Wu S. Deep learning of early brain imaging to predict post-arrest electroencephalography. Resuscitation 2022; 172:17-23. [PMID: 35041875 PMCID: PMC8923981 DOI: 10.1016/j.resuscitation.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Guidelines recommend use of computerized tomography (CT) and electroencephalography (EEG) in post-arrest prognostication. Strong associations between CT and EEG might obviate the need to acquire both modalities. We quantified these associations via deep learning. METHODS We performed a single-center, retrospective study including comatose patients hospitalized after cardiac arrest. We extracted brain CT DICOMs, resized and registered each to a standard anatomical atlas, performed skull stripping and windowed images to optimize contrast of the gray-white junction. We classified initial EEG as generalized suppression, other highly pathological findings or benign activity. We extracted clinical information available on presentation from our prospective registry. We trained three machine learning (ML) models to predict EEG from clinical covariates. We used three state-of-the-art approaches to build multi-headed deep learning models using similar model architectures. Finally, we combined the best performing clinical and imaging models. We evaluated discrimination in test sets. RESULTS We included 500 patients, of whom 218 (44%) had benign EEG findings, 135 (27%) showed generalized suppression and 147 (29%) had other highly pathological findings that were most commonly (93%) burst suppression with identical bursts. Clinical ML models had moderate discrimination (test set AUCs 0.73-0.80). Image-based deep learning performed worse (test set AUCs 0.51-0.69), particularly discriminating benign from highly pathological findings. Adding image-based deep learning to clinical models improved prediction of generalized suppression due to accurate detection of severe cerebral edema. DISCUSSION CT and EEG provide complementary information about post-arrest brain injury. Our results do not support selective acquisition of only one of these modalities, except in the most severely injured patients.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Neurology Division, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Chang Liu
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew Pease
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dooman Arefan
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick J. Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katharyn Flickinger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph M. Mettenburg
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria E. Baldwin
- Department of Neurology, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
| | - Niravkumar Barot
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shandong Wu
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA,Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA,Intelligent Systems Program, University of Pittsburgh, Pittsburgh, PA, USA
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Wang GN, Zhang ZM, Chen W, Xu XQ, Zhang JS. Timing of brain computed tomography for predicting neurological prognosis in comatose cardiac arrest survivors: a retrospective observational study. World J Emerg Med 2022; 13:349-354. [PMID: 36119778 PMCID: PMC9420655 DOI: 10.5847/wjem.j.1920-8642.2022.080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/18/2022] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND To assess the association between relevant brain computed tomography (CT) parameters at different time and neurological prognosis in adult comatose survivors after cardiac arrest (CA). METHODS A total of 94 CA patients who underwent early and late CT scans (within 24 h and 24 h to 7 d respectively after CA) between January 2018 and April 2020 were enrolled in this retrospective study. According to the Cerebral Performance Category (CPC) score at hospital discharge, the patients were divided into either a good outcome (CPC 1-2) group or a poor-outcome group (CPC 3-5). The grey-to-white matter ratio (GWR) and the proportion of cerebrospinal fluid volume (pCSFV) were measured. In predicting poor outcomes, the prognostic performance of relevant CT parameters was evaluated, and the comparison analysis (expressed as the ratio of parameters in late CT to those in the early CT) of different CT time was conducted. RESULTS Totally 26 patients were in the good-outcome group, while 68 patients were in the poor-outcome group. The putamen density, GWR, and pCSFV in late CT were significantly lower in the poor-outcome group (P<0.05). The ratios of GWR and pCSFV in the poor-outcome group were significantly decreased according to comparison analysis of different CT time (P<0.05), while there was no significant difference in the ratio of putamen density. GWR-basal ganglia <1.18 in late CT showed the best predictive value. The ratio of pCSFV <0.98 predicted unfavorable neurological outcomes with a sensitivity of 65.9% and a specificity of 93.8% (P=0.001). CONCLUSIONS Brain CT performed >24 h after CA may be a good choice as a neuroimaging approach to evaluating prognosis. To predict neurological prognosis, comparison analysis of different CT time can be used as another promising tool in comatose CA survivors.
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Affiliation(s)
- Gan-nan Wang
- Department of Emergency, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Zhong-man Zhang
- Department of Emergency, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Wen Chen
- Department of Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Xiao-quan Xu
- Department of Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Jin-song Zhang
- Department of Emergency, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
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Hayashi K, Uchida K, Ota H, Tanaka H, Maezawa M, Matsui H. Case report: Autonomic and endocrine response in the process of brain death in a child with hypoxic-ischemic brain injury. Front Pediatr 2022; 10:954651. [PMID: 35935365 PMCID: PMC9352937 DOI: 10.3389/fped.2022.954651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The causes of brain death include cerebral herniation and brainstem ischemia. Neuroendocrine failure or a series of autonomic nervous system disorders are clinically recognized in the transition to brain death among patients with critical brain injuries. An accurate evaluation of these physiologic instabilities and biomarkers is essential to assess the severity and prognosis of pediatric brain injury as well as to initiate supportive care. This case report presents a detailed evaluation of the autonomic nervous system and endocrine function during the transition to brain death in infantile hypoxic-ischemic brain injury by analyzing the heart rate variability and endocrine status. CASE PRESENTATION A 1-year-old previously healthy boy went into cardiac arrest after choking on a toy at home. Although spontaneous circulation returned 60 min after cardiopulmonary resuscitation, no cerebral activity or brainstem reflexes were observed after 18 hospital days. The heart rate variability was assessed by analyzing the generic electrocardiogram data. Rapid spikes or drops in the total power of the heart rate variability, accompanied by a cortisol surge, as well as an alternating surge of high- and low-frequency domain variables were detected in the process of brain death. CONCLUSION The heart rate variability assessment combined with endocrine provides a better understanding of the clinical course of patients undergoing brain death. It accurately detects the loss of brainstem function, which allows physicians to provide the appropriate supportive care.
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Affiliation(s)
- Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Kaname Uchida
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Hidehito Ota
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroyuki Tanaka
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Mieko Maezawa
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Hikoro Matsui
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
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GFAp and tau protein as predictors of neurological outcome after out-of-hospital cardiac arrest: A post hoc analysis of the COMACARE trial. Resuscitation 2021; 170:141-149. [PMID: 34863908 PMCID: PMC8786666 DOI: 10.1016/j.resuscitation.2021.11.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/15/2022]
Abstract
Aim To determine the ability of serum glial fibrillary acidic protein (GFAp) and tau protein to predict neurological outcome after out-of-hospital cardiac arrest (OHCA). Methods We measured plasma concentrations of GFAp and tau of patients included in the previously published COMACARE trial (NCT02698917) on intensive care unit admission and at 24, 48, and 72 h after OHCA, and compared them to neuron specific enolase (NSE). NSE concentrations were determined already during the original trial. We defined unfavourable outcome as a cerebral performance category (CPC) score of 3–5 six months after OHCA. We determined the prognostic accuracy of GFAp and tau using the receiver operating characteristic curve and area under the curve (AUROC). Results Overall, 39/112 (35%) patients had unfavourable outcomes. Over time, both markers were evidently higher in the unfavourable outcome group (p < 0.001). At 48 h, the median (interquartile range) GFAp concentration was 1514 (886–4995) in the unfavourable versus 238 (135–463) pg/ml in the favourable outcome group (p < 0.001). The corresponding tau concentrations were 99.6 (14.5–352) and 3.0 (2.2–4.8) pg/ml (p < 0.001). AUROCs at 48 and 72 h were 0.91 (95% confidence interval 0.85–0.97) and 0.91 (0.85–0.96) for GFAp and 0.93 (0.86–0.99) and 0.95 (0.89–1.00) for tau. Corresponding AUROCs for NSE were 0.86 (0.79–0.94) and 0.90 (0.82–0.97). The difference between the prognostic accuracies of GFAp or tau and NSE were not statistically significant. Conclusions At 48 and 72 h, serum both GFAp and tau demonstrated excellent accuracy in predicting outcomes after OHCA but were not superior to NSE. Clinical trial registration NCT02698917 (https://www.clinicaltrials.gov/ct2/show/NCT02698917).
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Kirsch K, Heymel S, Günther A, Vahl K, Schmidt T, Michalski D, Fritzenwanger M, Schulze PC, Pfeifer R. Prognostication of neurologic outcome using gray-white-matter-ratio in comatose patients after cardiac arrest. BMC Neurol 2021; 21:456. [PMID: 34809608 PMCID: PMC8607613 DOI: 10.1186/s12883-021-02480-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/05/2021] [Indexed: 01/14/2023] Open
Abstract
Background This study aimed to assess the prognostic value regarding neurologic outcome of CT neuroimaging based Gray-White-Matter-Ratio measurement in patients after resuscitation from cardiac arrest. Methods We retrospectively evaluated CT neuroimaging studies of 91 comatose patients resuscitated from cardiac arrest and 46 non-comatose controls. We tested the diagnostic performance of Gray-White-Matter-Ratio compared with established morphologic signs of hypoxic-ischaemic brain injury, e. g. loss of distinction between gray and white matter, and laboratory parameters, i. e. neuron-specific enolase, for the prediction of poor neurologic outcomes after resuscitated cardiac arrest. Primary endpoint was neurologic function assessed with cerebral performance category score 30 days after the index event. Results Gray-White-Matter-Ratio showed encouraging interobserver variability (ICC 0.670 [95% CI: 0.592–0.741] compared to assessment of established morphologic signs of hypoxic-ischaemic brain injury (Fleiss kappa 0.389 [95% CI: 0.320–0.457]) in CT neuroimaging studies. It correlated with cerebral performance category score with lower Gray-White-Matter-Ratios associated with unfavourable neurologic outcomes. A cut-off of 1.17 derived from the control population predicted unfavourable neurologic outcomes in adult survivors of cardiac arrest with 100% specificity, 50.3% sensitivity, 100% positive predictive value, and 39.3% negative predictive value. Gray-White-Matter-Ratio prognostic power depended on the time interval between circulatory arrest and CT imaging, with increasing sensitivity the later the image acquisition was executed. Conclusions A reduced Gray-White-Matter-Ratio is a highly specific prognostic marker of poor neurologic outcomes early after resuscitation from cardiac arrest. Sensitivity seems to be dependent on the time interval between circulatory arrest and image acquisition, with limited value within the first 12 h.
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Affiliation(s)
- Konrad Kirsch
- Department of Internal Medicine I, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
| | - Stefan Heymel
- Department of Internal Medicine I, Division of Medical Intensive Care, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Kathleen Vahl
- Department of Radiology, Interventional Radiology and Neuroradiology, Klinikum Altenburger Land, Am Waldessaum 10, 04600, Altenburg, Germany
| | - Thorsten Schmidt
- Department of Diagnostic and Interventional Neuroradiology, HELIOS Klinikum Wuppertal, Heusnerstraße 40, 42283, Wuppertal, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Michael Fritzenwanger
- Department of Internal Medicine I, Division of Medical Intensive Care, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Paul Christian Schulze
- Department of Internal Medicine I, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Rüdiger Pfeifer
- Department of Internal Medicine I, Division of Medical Intensive Care, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
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Update to the dataset of cerebral ischemia in juvenile pigs with evoked potentials. Sci Data 2021; 8:248. [PMID: 34556666 PMCID: PMC8460715 DOI: 10.1038/s41597-021-01029-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/12/2021] [Indexed: 11/23/2022] Open
Abstract
We expand from a spontaneous to an evoked potentials (EP) data set of brain electrical activities as electrocorticogram (ECoG) and electrothalamogram (EThG) in juvenile pig under various sedation, ischemia and recovery states. This EP data set includes three stimulation paradigms: auditory (AEP, 40 and 2000 Hz), sensory (SEP, left and right maxillary nerve) and high-frequency oscillations (HFO) SEP. This permits derivation of electroencephalogram (EEG) biomarkers of corticothalamic communication under these conditions. The data set is presented in full band sampled at 2000 Hz. We provide technical validation of the evoked responses for the states of sedation, ischemia and recovery. This extended data set now permits mutual inferences between spontaneous and evoked activities across the recorded modalities. Future studies on the dataset may contribute to the development of new brain monitoring technologies, which will facilitate the prevention of neurological injuries. Measurement(s) | Abnormal auditory evoked potentials • Abnormality of somatosensory evoked potentials • high frequency oscillations • brain activity | Technology Type(s) | Electrocorticography • electrothalamography | Factor Type(s) | anesthesia • analgosedation • sedation • cerebral ischemia | Sample Characteristic - Organism | Sus scrofa |
Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.16462875
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Wiklund L, Sharma A, Patnaik R, Muresanu DF, Sahib S, Tian ZR, Castellani RJ, Nozari A, Lafuente JV, Sharma HS. Upregulation of hemeoxygenase enzymes HO-1 and HO-2 following ischemia-reperfusion injury in connection with experimental cardiac arrest and cardiopulmonary resuscitation: Neuroprotective effects of methylene blue. PROGRESS IN BRAIN RESEARCH 2021; 265:317-375. [PMID: 34560924 DOI: 10.1016/bs.pbr.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Oxidative stress plays an important role in neuronal injuries after cardiac arrest. Increased production of carbon monoxide (CO) by the enzyme hemeoxygenase (HO) in the brain is induced by the oxidative stress. HO is present in the CNS in two isoforms, namely the inducible HO-1 and the constitutive HO-2. Elevated levels of serum HO-1 occurs in cardiac arrest patients and upregulation of HO-1 in cardiac arrest is seen in the neurons. However, the role of HO-2 in cardiac arrest is not well known. In this review involvement of HO-1 and HO-2 enzymes in the porcine brain following cardiac arrest and resuscitation is discussed based on our own observations. In addition, neuroprotective role of methylene blue- an antioxidant dye on alterations in HO under in cardiac arrest is also presented. The biochemical findings of HO-1 and HO-2 enzymes using ELISA were further confirmed by immunocytochemical approach to localize selective regional alterations in cardiac arrest. Our observations are the first to show that cardiac arrest followed by successful cardiopulmonary resuscitation results in significant alteration in cerebral concentrations of HO-1 and HO-2 levels indicating a prominent role of CO in brain pathology and methylene blue during CPR followed by induced hypothermia leading to superior neuroprotection after return of spontaneous circulation (ROSC), not reported earlier.
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Affiliation(s)
- Lars Wiklund
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
| | - Ranjana Patnaik
- Department of Biomaterials, School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, India
| | - Dafin F Muresanu
- Department of Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania; "RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Seaab Sahib
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Z Ryan Tian
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Rudy J Castellani
- Department of Pathology, University of Maryland, Baltimore, MD, United States
| | - Ala Nozari
- Anesthesiology & Intensive Care, Massachusetts General Hospital, Boston, MA, United States
| | - José Vicente Lafuente
- LaNCE, Department of Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Bizkaia, Spain
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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Automated Assessment of Brain CT After Cardiac Arrest-An Observational Derivation/Validation Cohort Study. Crit Care Med 2021; 49:e1212-e1222. [PMID: 34374503 DOI: 10.1097/ccm.0000000000005198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives Prognostication of outcome is an essential step in defining therapeutic goals after cardiac arrest. Gray-white-matter ratio obtained from brain CT can predict poor outcome. However, manual placement of regions of interest is a potential source of error and interrater variability. Our objective was to assess the performance of poor outcome prediction by automated quantification of changes in brain CTs after cardiac arrest. Design Observational, derivation/validation cohort study design. Outcome was determined using the Cerebral Performance Category upon hospital discharge. Poor outcome was defined as death or unresponsive wakefulness syndrome/coma. CTs were automatically decomposed using coregistration with a brain atlas. Setting ICUs at a large, academic hospital with circulatory arrest center. Patients We identified 433 cardiac arrest patients from a large previously established database with brain CTs within 10 days after cardiac arrest. Interventions None. Measurements and Main Results Five hundred sixteen brain CTs were evaluated (derivation cohort n = 309, validation cohort n = 207). Patients with poor outcome had significantly lower radiodensities in gray matter regions. Automated GWR_si (putamen/posterior limb of internal capsule) was performed with an area under the curve of 0.86 (95%-CI: 0.80-0.93) for CTs taken later than 24 hours after cardiac arrest (similar performance in the validation cohort). Poor outcome (Cerebral Performance Category 4-5) was predicted with a specificity of 100% (95% CI, 87-100%, derivation; 88-100%, validation) at a threshold of less than 1.10 and a sensitivity of 49% (95% CI, 36-58%, derivation) and 38% (95% CI, 27-50%, validation) for CTs later than 24 hours after cardiac arrest. Sensitivity and area under the curve were lower for CTs performed within 24 hours after cardiac arrest. Conclusions Automated gray-white-matter ratio from brain CT is a promising tool for prediction of poor neurologic outcome after cardiac arrest with high specificity and low-to-moderate sensitivity. Prediction by gray-white-matter ratio at the basal ganglia level performed best. Sensitivity increased considerably for CTs performed later than 24 hours after cardiac arrest.
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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43
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Inhaled gases as novel neuroprotective therapies in the postcardiac arrest period. Curr Opin Crit Care 2021; 27:255-260. [PMID: 33769417 DOI: 10.1097/mcc.0000000000000820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent advances about inhaled gases as novel neuroprotective agents in the postcardiac arrest period. RECENT FINDINGS Inhaled gases, as nitric oxide (NO) and molecular hydrogen (H2), and noble gases as xenon (Xe) and argon (Ar) have shown neuroprotective properties after resuscitation. In experimental settings, the protective effect of these gases has been demonstrated in both in-vitro studies and animal models of cardiac arrest. They attenuate neuronal degeneration and improve neurological function after resuscitation acting on different pathophysiological pathways. Safety of both Xe and H2 after cardiac arrest has been reported in phase 1 clinical trials. A randomized phase 2 clinical trial showed the neuroprotective effects of Xe, combined with targeted temperature management. Xe inhalation for 24 h after resuscitation preserves white matter integrity as measured by fractional anisotropy of diffusion tensor MRI. SUMMARY Inhaled gases, as Xe, Ar, NO, and H2 have consistently shown neuroprotective effects in experimental studies. Ventilation with these gases appears to be well tolerated in pigs and in preliminary human trials. Results from phase 2 and 3 clinical trials are needed to assess their efficacy in the treatment of postcardiac arrest brain injury.
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Peluso L, Gaspard N. Electroencephalography in post-cardiac arrest patients: a matter of timing? Minerva Anestesiol 2021; 87:637-639. [PMID: 33938681 DOI: 10.23736/s0375-9393.21.15715-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Lorenzo Peluso
- Department of Intensive Care, Cliniques Universitaires de Bruxelles - Erasme Hospital, Brussels, Belgium -
| | - Nicolas Gaspard
- Department of Neurology, Cliniques Universitaires de Bruxelles - Erasme Hospital, Brussels, Belgium.,Department of Neurology, Yale University Medical School, New Haven, CT, USA
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45
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Elmer J, Kane N. Evoking signs of recovery after cardiac arrest: The SSEP 'present versus absent' dichotomy has shifted, now size matters. Resuscitation 2021; 163:195-197. [PMID: 33930503 DOI: 10.1016/j.resuscitation.2021.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Jonathan Elmer
- Departments of Emergency Medicine, Critical Care Medicine and Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Nick Kane
- The Grey Walter Department of Clinical Neurophysiology, Southmead Hospital, Bristol, BS10 5NB, UK
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van Soest TM, van Rootselaar AF, Admiraal MM, Potters WV, Koelman JHMT, Horn J. SSEP amplitudes add information for prognostication in postanoxic coma. Resuscitation 2021; 163:172-175. [PMID: 33848583 DOI: 10.1016/j.resuscitation.2021.03.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/22/2021] [Accepted: 03/31/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate whether somatosensory evoked potential (SSEP) amplitude adds information for prediction of poor outcome in postanoxic coma. METHODS In this retrospective cohort study we included adult patients admitted after cardiac arrest between January 2010 and June 2018 who remained in coma and had SSEP recorded for prognostication. Outcome was dichotomized in poor (Cerebral Performance Category (CPC) 4-5) and good (CPC 1-3) at ICU discharge. Sensitivity of bilaterally absent N20 potential was calculated. In case the N20 potential was not bilaterally absent, the amplitude contralateral to stimulation side (baseline-N20, N20-P25, and maximum) was determined. At a specificity of 100%, SEPP amplitude sensitivities were determined for poor outcome. RESULTS SSEP recordings were performed in 197 patients of whom 57 had bilaterally absent N20 potentials. From 140 patients, 16 (11%) had a good outcome. The sensitivity for poor outcome of bilaterally absent N20 was 31%. At a specificity of 100%, contralateral amplitude thresholds were 0.34 μV (baseline-N20), 0.99 μV (N20-P25) and 1.0 μV (maximum), corresponding to a sensitivity for poor outcome of 38%, 44% and 40%. Combination of bilaterally absent N20 and a N20-P25 threshold below 0.99 μV yielded a sensitivity of 62%. CONCLUSIONS Our results confirm that very low cortical SSEP amplitudes are highly predictive of poor outcome in patients with postanoxic coma. Adding 'N20-P25 threshold amplitude' to the 'bilaterally absent N20' criterion, increased sensitivity substantially.
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Affiliation(s)
- Thijs M van Soest
- Department of Intensive Care, Amsterdam UMC and University of Amsterdam, The Netherlands; Department of Neurology/Clinical Neurophysiology, Amsterdam UMC and University of Amsterdam, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands.
| | - Anne-Fleur van Rootselaar
- Department of Neurology/Clinical Neurophysiology, Amsterdam UMC and University of Amsterdam, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Marjolein M Admiraal
- Department of Neurology/Clinical Neurophysiology, Amsterdam UMC and University of Amsterdam, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Wouter V Potters
- Department of Neurology/Clinical Neurophysiology, Amsterdam UMC and University of Amsterdam, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Johannes H M T Koelman
- Department of Neurology/Clinical Neurophysiology, Amsterdam UMC and University of Amsterdam, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam UMC and University of Amsterdam, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands
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47
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SSEP amplitude accurately predicts both good and poor neurological outcome early after cardiac arrest; a post-hoc analysis of the ProNeCA multicentre study. Resuscitation 2021; 163:162-171. [PMID: 33819501 DOI: 10.1016/j.resuscitation.2021.03.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/17/2021] [Accepted: 03/26/2021] [Indexed: 11/23/2022]
Abstract
AIM To assess if, in comatose resuscitated patients, the amplitude of the N20 wave (N20amp) of somatosensory evoked potentials (SSEP) can predict 6-months neurological outcome. SETTING Multicentre study in 13 Italian intensive care units. METHODS The N20amp in microvolts (μV) was measured at 12 h, 24 h, and 72 h from cardiac arrest, along with pupillary reflex (PLR) and a 30-min EEG classified according to the ACNS terminology. Sensitivity and false positive rate (FPR) of N20amp alone or in combination were calculated. RESULTS 403 patients (age 69[58-68] years) were included. At 12 h, an N20amp >3 μV predicted good neurological outcome (Cerebral Performance Categories [CPC] 1-2) with 61[50-72]% sensitivity and 11[6-18]% FPR. Combining it with a benign (continuous or nearly continuous) EEG increased sensitivity to 91[82-96]%. For poor outcome (CPC 3-5), an N20Amp ≤0.38 μV, ≤0.73 μV and ≤1.01 μV at 12 h, 24 h, and 72 h, respectively, had 0% FPR with sensitivity ranging from 61[51-69]% and 82[76-88]%. Sensitivity was higher than that of a bilaterally absent N20 at all time points. At 12 h and 24 h, a highly malignant (suppression or burst-suppression) EEG and bilaterally absent PLR achieved 0% FPR only when combined with SSEP. A combination of all three predictors yielded a 0[0-4]% FPR, with maximum sensitivity of 44[36-53]%. CONCLUSION At 12 h from arrest, a high N20Amp predicts good outcome with high sensitivity, especially when combined with benign EEG. At 12 h and 24 h from arrest a low-voltage N20amp has a high sensitivity and is more specific than EEG or PLR for predicting poor outcome.
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48
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 417] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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49
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 338] [Impact Index Per Article: 112.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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50
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Hayashida K, Miyara SJ, Shinozaki K, Takegawa R, Yin T, Rolston DM, Choudhary RC, Guevara S, Molmenti EP, Becker LB. Inhaled Gases as Therapies for Post-Cardiac Arrest Syndrome: A Narrative Review of Recent Developments. Front Med (Lausanne) 2021; 7:586229. [PMID: 33585501 PMCID: PMC7873953 DOI: 10.3389/fmed.2020.586229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/04/2020] [Indexed: 01/22/2023] Open
Abstract
Despite recent advances in the management of post-cardiac arrest syndrome (PCAS), the survival rate, without neurologic sequelae after resuscitation, remains very low. Whole-body ischemia, followed by reperfusion after cardiac arrest (CA), contributes to PCAS, for which established pharmaceutical interventions are still lacking. It has been shown that a number of different processes can ultimately lead to neuronal injury and cell death in the pathology of PCAS, including vasoconstriction, protein modification, impaired mitochondrial respiration, cell death signaling, inflammation, and excessive oxidative stress. Recently, the pathophysiological effects of inhaled gases including nitric oxide (NO), molecular hydrogen (H2), and xenon (Xe) have attracted much attention. Herein, we summarize recent literature on the application of NO, H2, and Xe for treating PCAS. Recent basic and clinical research has shown that these gases have cytoprotective effects against PCAS. Nevertheless, there are likely differences in the mechanisms by which these gases modulate reperfusion injury after CA. Further preclinical and clinical studies examining the combinations of standard post-CA care and inhaled gas treatment to prevent ischemia-reperfusion injury are warranted to improve outcomes in patients who are being failed by our current therapies.
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Affiliation(s)
- Kei Hayashida
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States
| | - Santiago J Miyara
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States.,Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States.,Department of Surgery, Medicine, and Pediatrics, Zucker School of Medicine at Hofstra/Northwell, New York, NY, United States.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Koichiro Shinozaki
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States
| | - Ryosuke Takegawa
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States
| | - Tai Yin
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States
| | - Daniel M Rolston
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States.,Department of Surgery, Northwell Health, Manhasset, NY, United States.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, United States
| | - Rishabh C Choudhary
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States
| | - Sara Guevara
- Department of Surgery, Northwell Health, Manhasset, NY, United States
| | - Ernesto P Molmenti
- Department of Surgery, Medicine, and Pediatrics, Zucker School of Medicine at Hofstra/Northwell, New York, NY, United States.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, United States
| | - Lance B Becker
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, United States.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, United States.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, United States
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