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Dolmans RG, Nahed BV, Robertson FC, Peul WC, Rosenthal ES, Broekman ML. Practice-Pattern Variation in Sedation of Neurotrauma Patients in the Intensive Care Unit: An International Survey. J Intensive Care Med 2023; 38:1143-1150. [PMID: 37415510 PMCID: PMC10616999 DOI: 10.1177/08850666231186563] [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: 04/18/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
Background: Analgo-sedation plays an important role during intensive care management of traumatic brain injury (TBI) patients, however, limited evidence is available to guide practice. We sought to quantify practice-pattern variation in neurotrauma sedation management, surveying an international sample of providers. Methods: An electronic survey consisting of 56 questions was distributed internationally to neurocritical care providers utilizing the Research Electronic Data Capture platform. Descriptive statistics were used to quantitatively describe and summarize the responses. Results: Ninety-five providers from 37 countries responded. 56.8% were attending physicians with primary medical training most commonly in intensive care medicine (68.4%) and anesthesiology (26.3%). Institutional sedation guidelines for TBI patients were available in 43.2%. Most common sedative agents for induction and maintenance, respectively, were propofol (87.5% and 88.4%), opioids (60.2% and 70.5%), and benzodiazepines (53.4% and 68.4%). Induction and maintenance sedatives, respectively, are mostly chosen according to provider preference (68.2% and 58.9%) rather than institutional guidelines (26.1% and 35.8%). Sedation duration for patients with intracranial hypertension ranged from 24 h to 14 days. Neurological wake-up testing (NWT) was routinely performed in 70.5%. The most common NWT frequency was every 24 h (47.8%), although 20.8% performed NWT at least every 2 h. Richmond Agitation and Sedation Scale targets varied from deep sedation (34.7%) to alert and calm (17.9%). Conclusions: Among critically ill TBI patients, sedation management follows provider preference rather than institutional sedation guidelines. Wide practice-pattern variation exists for the type, duration, and target of sedative management and NWT performance. Future comparative effectiveness research investigating these differences may help optimize sedation strategies to promote recovery.
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Affiliation(s)
- Rianne G.F. Dolmans
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian V. Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Faith C. Robertson
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wilco C. Peul
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, the Netherlands
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Neurosurgery, Leiden, the Netherlands
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marike L.D. Broekman
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, the Netherlands
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Gedeno K, Neme D, Jemal B, Aweke Z, Achule A, Geremu K, Bekele Uddo T. Evidence-based management of adult traumatic brain injury with raised intracranial pressure in intensive critical care unit at resource-limited settings: a literature review. Ann Med Surg (Lond) 2023; 85:5983-6000. [PMID: 38098558 PMCID: PMC10718354 DOI: 10.1097/ms9.0000000000001291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/02/2023] [Indexed: 12/17/2023] Open
Abstract
Background In underdeveloped countries, there is a greater incidence of mortality and morbidity arising from trauma, with traumatic brain injury (TBI) accounting for 50% of all trauma-related deaths. The occurrence of elevated intracranial pressure (ICP), which is a common pathophysiological phenomenon in cases of TBI, acts as a contributing factor to unfavorable outcomes. The aim of this systematic review is to analyze the existing literature regarding the management of adult TBI with raised ICP in an intensive critical care unit, despite limited resources. Methods This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis protocol. Search engines such as PubMed, the Cochrane database, and Google Scholar were utilized to locate high-level evidence that would facilitate the formation of sound conclusions. Result A total of 11 715 articles were identified and individually assessed to determine their eligibility for inclusion or exclusion based on predetermined criteria and outcome variables. The methodological quality of each study was evaluated using recommended criteria. Ultimately, the review consisted of 51 articles. Conclusion Physical examination results and noninvasive assessments of the optic nerve sheath diameter (ONSD) via sonography are positively associated with elevated ICP, and are employed as diagnostic and monitoring tools for elevated ICP in resource-limited settings. Management of elevated ICP necessitates an algorithmic approach that utilizes prophylactic measures and acute intervention treatments to mitigate the risk of secondary brain injury.
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Affiliation(s)
- Kanbiro Gedeno
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | | | | | - Zemedu Aweke
- Department of Anesthesia
- School of Clinical Science, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Astemamagn Achule
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | - Kuchulo Geremu
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | - Tesfanew Bekele Uddo
- Department of Surgery, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia
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ElSaban M, Bhatt G, Lee J, Koshiya H, Mansoor T, Amal T, Kashyap R. A historical delve into neurotrauma-focused critical care. Wien Med Wochenschr 2023; 173:368-373. [PMID: 36729341 PMCID: PMC9892675 DOI: 10.1007/s10354-022-01002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/27/2022] [Indexed: 02/03/2023]
Abstract
Neurocritical care is a multidisciplinary field managing patients with a wide range of aliments. Specifically, neurotrauma is a rapidly growing field with increasing demands. The history of how neurotrauma management came to its current form has not been extensively explored before. Our review delves into the history, timeline, and noteworthy pioneers of neurotrauma-focused neurocritical care. We explore the historical development during early times, the 18th-20th centuries, and modern times, as well as warfare- and sports-related concussions. Research is ever growing in this budding field, with several promising innovations on the horizon.
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Affiliation(s)
- Mariam ElSaban
- Department of Anesthesiology, Mayo Clinic, Rochester, MN USA
| | - Gaurang Bhatt
- All India Institute of Medical Sciences, Rishikesh, India
| | - Joanna Lee
- David Tvildiani Medical University, Tbilisi, Georgia
| | - Hiren Koshiya
- Department of Hematology & Oncology, Mayo Clinic, Jacksonville, USA Florida
| | | | - Tanya Amal
- Maulana Azad Medical College, New Delhi, India
| | - Rahul Kashyap
- Department of Critical Care Medicine, Mayo Clinic, Rochester, MN USA
- Medical director research, WellSpan Health, New York, PA USA
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Jeffcote T, Weir T, Anstey J, Mcnamara R, Bellomo R, Udy A. The Impact of Sedative Choice on Intracranial and Systemic Physiology in Moderate to Severe Traumatic Brain Injury: A Scoping Review. J Neurosurg Anesthesiol 2023; 35:265-273. [PMID: 35142704 DOI: 10.1097/ana.0000000000000836] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/06/2022] [Indexed: 11/27/2022]
Abstract
Although sedative use is near-ubiquitous in the acute management of moderate to severe traumatic brain injury (m-sTBI), the evidence base for these agents is undefined. This review summarizes the evidence for analgosedative agent use in the intensive care unit management of m-sTBI. Clinical studies of sedative and analgosedative agents currently utilized in adult m-sTBI management (propofol, ketamine, benzodiazepines, opioids, and alpha-2 agonists) were identified and assessed for relevance and methodological quality. The primary outcome was the effect of the analgosedative agent on intracranial pressure (ICP). Secondary outcomes included intracranial hemodynamic and metabolic parameters, systemic hemodynamic parameters, measures of therapeutic intensity, and clinical outcomes. Of 594 articles identified, 61 met methodological review criteria, and 40 were included in the qualitative summary; of these, 33 were prospective studies, 18 were randomized controlled trials, and 8 were blinded. There was consistent evidence for the efficacy of sedative agents in the management of m-sTBI and raised ICP, but the overall quality of the evidence was poor, consisting of small studies (median sample size, 23.5) of variable methodological quality. Propofol and midazolam achieve the goals of sedation without notable differences in efficacy or safety, although high-dose propofol may disrupt cerebral autoregulation. Dexmedetomidine and propofol/ dexmedetomidine combination may cause clinically significant hypotension. Dexmedetomidine was effective to achieve a target sedation score. De novo opioid boluses were associated with increased ICP and reduced cerebral perfusion pressure. Ketamine bolus and infusions were not associated with increased ICP and may reduce the incidence of cortical spreading depolarization events. In conclusion, there is a paucity of high-quality evidence to inform the optimal use of analgosedative agents in the management of m-sTBI, inferring significant scope for further research.
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Affiliation(s)
- Toby Jeffcote
- Department of Intensive Care Medicine, The Alfred Hospital
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
| | - Timothy Weir
- Department of Intensive Care Medicine, The Alfred Hospital
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne
| | - Robert Mcnamara
- Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The Austin Hospital
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne
- Department of Critical Care, University of Melbourne, Parkville
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
| | - Andrew Udy
- Department of Intensive Care Medicine, The Alfred Hospital
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
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5
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Understanding Acquired Brain Injury: A Review. Biomedicines 2022; 10:biomedicines10092167. [PMID: 36140268 PMCID: PMC9496189 DOI: 10.3390/biomedicines10092167] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/02/2022] [Accepted: 08/26/2022] [Indexed: 01/19/2023] Open
Abstract
Any type of brain injury that transpires post-birth is referred to as Acquired Brain Injury (ABI). In general, ABI does not result from congenital disorders, degenerative diseases, or by brain trauma at birth. Although the human brain is protected from the external world by layers of tissues and bone, floating in nutrient-rich cerebrospinal fluid (CSF); it remains susceptible to harm and impairment. Brain damage resulting from ABI leads to changes in the normal neuronal tissue activity and/or structure in one or multiple areas of the brain, which can often affect normal brain functions. Impairment sustained from an ABI can last anywhere from days to a lifetime depending on the severity of the injury; however, many patients face trouble integrating themselves back into the community due to possible psychological and physiological outcomes. In this review, we discuss ABI pathologies, their types, and cellular mechanisms and summarize the therapeutic approaches for a better understanding of the subject and to create awareness among the public.
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Second- and Third-Tier Therapies for Severe Traumatic Brain Injury. J Clin Med 2022; 11:jcm11164790. [PMID: 36013029 PMCID: PMC9410180 DOI: 10.3390/jcm11164790] [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: 07/18/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 12/04/2022] Open
Abstract
Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.
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Current and Potential Pharmacologic Therapies for Traumatic Brain Injury. Pharmaceuticals (Basel) 2022; 15:ph15070838. [PMID: 35890136 PMCID: PMC9323622 DOI: 10.3390/ph15070838] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 02/04/2023] Open
Abstract
The present article reviewed the pharmacologic therapies of traumatic brain injury (TBI), including current and potential treatments. Pharmacologic therapies are an essential part of TBI care, and several agents have well-established effects in TBI care. In the acute phase, tranexamic acid, antiepileptics, hyperosmolar agents, and anesthetics are the mainstay of pharmacotherapy, which have proven efficacies. In the post-acute phase, SSRIs, SNRIs, antipsychotics, zolpidem and amantadine, as well as other drugs, have been used to manage neuropsychological problems, while muscle relaxants and botulinum toxin have been used to manage spasticity. In addition, increasing numbers of pre-clinical and clinical studies of pharmaceutical agents, including potential neuroprotective nutrients and natural therapies, are being carried out. In the present article, we classify the treatments into established and potential agents based on the level of clinical evidence and standard of practice. It is expected that many of the potential medicines under investigation will eventually be accepted as standard practice in the care of TBI patients.
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Huang Y, Deng Y, Zhang R, Meng M, Chen D. Comparing the Effect of Dexmedetomidine and Midazolam in Patients with Brain Injury. Brain Sci 2022; 12:brainsci12060752. [PMID: 35741637 PMCID: PMC9221420 DOI: 10.3390/brainsci12060752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/01/2022] [Accepted: 06/04/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Studies have shown that dexmedetomidine improves neurological function. Whether dexmedetomidine reduces mortality or improves quantitative electroencephalography (qEEG) among patients post-craniotomy remains unclear. METHODS This single-center randomized study was conducted prospectively from 1 January 2019 to 31 December 2020. Patients who were transferred to the ICU after craniotomy within 24 h were included. The analgesic was titrated to a Critical care Pain Observation Tool (CPOT) score ≤2, and the sedative was titrated to a Richmond Agitation-Sedation Scale (RASS) score ≤-3 for at least 24 h. The qEEG signals were collected by four electrodes (F3, T3, F4, and T4 according to the international 10/20 EEG electrode practice). The primary outcome was 28-day mortality and qEEG results on day 1 and day 3 after sedation. RESULTS One hundred and fifty-one patients were enrolled in this study, of whom 77 were in the dexmedetomidine group and 74 in the midazolam group. No significant difference was found between the two groups in mortality at 28 days (14.3% vs. 24.3%; p = 0.117) as well as in the theta/beta ratio (TBR), the delta/alpha ratio (DAR), and the (delta + theta)/(alpha + beta) ratio (DTABR) between the two groups on day 1 or day 3. However, both the TBR and the DTABR were significantly increased in the dexmedetomidine group. The DTABR in the midazolam group was significantly increased. The DAR was significantly increased on the right side in the dexmedetomidine group (20.4 (11.6-43.3) vs. 35.1 (16.7-65.0), p = 0.006) as well as on both sides in the midazolam group (Left: 19.5 (10.1-35.8) vs. 37.3 (19.3-75.7), p = 0.006; Right: 18.9 (10.1-52.3) vs. 39.8 (17.5-99.9), p = 0.002). CONCLUSION Compared with midazolam, dexmedetomidine did not lead to a lower 28-day mortality or better qEEG results in brain injury patients after a craniotomy.
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9
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Léger M, Frasca D, Roquilly A, Seguin P, Cinotti R, Dahyot-Fizelier C, Asehnoune K, Le Borgne F, Gaillard T, Foucher Y, Lasocki S. Early use of barbiturates is associated with increased mortality in traumatic brain injury patients from a propensity score-based analysis of a prospective cohort. PLoS One 2022; 17:e0268013. [PMID: 35507627 PMCID: PMC9067881 DOI: 10.1371/journal.pone.0268013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/20/2022] [Indexed: 01/29/2023] Open
Abstract
Barbiturates are proposed as a second/third line treatment for intracranial hypertension in traumatic brain injury (TBI) patients, but the literature remains uncertain regarding their benefit/risk balance. We aimed to evaluate the impact of barbiturates therapy in TBI patients with early intracranial hypertension on the intensive care unit (ICU) survival, the occurrence of ventilator-associated pneumonia (VAP), and the patient’s functional status at three months. We used the French AtlanREA prospective cohort of trauma patients. Using a propensity score-based methodology (inverse probability of treatment weighting), we compared patients having received barbiturates within the first 24 hours of admission (barbiturates group) and those who did not (control group). We used cause-specific Cox models for ICU survival and risk of VAP, and logistic regression for the 3-month Glasgow Outcome Scale (GOS) evaluation. Among the 1396 patients with severe trauma, 383 had intracranial hypertension on admission and were analyzed. Among them, 96 (25.1%) received barbiturates. The early use of barbiturates was significantly associated with increased ICU mortality (HR = 1.85, 95%CI 1.03–3.33). However, barbiturates treatment was not significantly associated with VAP (HR = 1.02, 95%CI 0.75–1.41) or 3-month GOS (OR = 1.67, 95%CI 0.84–3.33). Regarding the absence of relevant clinical trials, our results suggest that each early prescription of barbiturates requires a careful assessment of the benefit/risk ratio.
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Affiliation(s)
- Maxime Léger
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire d’Angers, Angers, France
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- * E-mail:
| | - Denis Frasca
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Antoine Roquilly
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Philippe Seguin
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Raphaël Cinotti
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Claire Dahyot-Fizelier
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Karim Asehnoune
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Florent Le Borgne
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- IDBC-A2COM, Pacé, France
| | - Thomas Gaillard
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Yohann Foucher
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Sigismond Lasocki
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire d’Angers, Angers, France
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Al-Mufti F, Mayer SA, Kaur G, Bassily D, Li B, Holstein ML, Ani J, Matluck NE, Kamal H, Nuoman R, Bowers CA, S Ali F, Al-Shammari H, El-Ghanem M, Gandhi C, Amuluru K. Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism. Neuroradiol J 2021; 34:542-551. [PMID: 34476991 PMCID: PMC8649190 DOI: 10.1177/19714009211024633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND PURPOSE Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Daniel Bassily
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Boyi Li
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Matthew L Holstein
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Jood Ani
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Nicole E Matluck
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Maria Fareri Children’s Hospital, Westchester Medical Center, Valhalla, USA
| | | | - Faizan S Ali
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Hussein Al-Shammari
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona, Tucson, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Indianapolis, USA
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Lachance BB, Chang W, Motta M, Parikh G, Podell J, Badjatia N, Simard JM, Schwartzbauer GT, Morris NA. Verticalization for Refractory Intracranial Hypertension: A Case Series. Neurocrit Care 2021; 36:463-470. [PMID: 34405321 DOI: 10.1007/s12028-021-01323-z] [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: 05/19/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Severe intracranial hypertension is strongly associated with mortality. Guidelines recommend medical management involving sedation, hyperosmotic agents, barbiturates, hypothermia, and surgical intervention. When these interventions are maximized or are contraindicated, refractory intracranial hypertension poses risk for herniation and death. We describe a novel intervention of verticalization for treating intracranial hypertension refractory to aggressive medical treatment. METHODS This study was a single-center retrospective review of six cases of refractory intracranial hypertension in a tertiary care center. All patients were treated with a standard-of-care algorithm for lowering intracranial pressure (ICP) yet maintained an ICP greater than 20 mmHg. They were then treated with verticalization for at least 24 h. We compared the median ICP, the number of ICP spikes greater than 20 mmHg, and the percentage of ICP values greater than 20 mmHg in the 24 h before verticalization vs. after verticalization. We assessed the use of hyperosmotic therapies and any changes in the mean arterial pressure and cerebral perfusion pressure related with the intervention. RESULTS Five patients were admitted with subarachnoid hemorrhage and one with intracerebral hemorrhage. All patients had ICP monitoring by external ventricular drain. The median opening pressure was 30 mmHg (25th-75th interquartile range 22.5-30 mmHg). All patients demonstrated a reduction in ICP after verticalization, with a significant decrease in the median ICP (12 vs. 8 mmHg; p < 0.001), the number of ICP spikes (12 vs. 2; p < 0.01), and the percentage of ICP values greater than 20 mmHg (50% vs. 8.3%; p < 0.01). There was a decrease in total medical interventions after verticalization (79 vs. 41; p = 0.05) and a lower total therapy intensity level score after verticalization. The most common adverse effects included asymptomatic bradycardia (n = 3) and pressure wounds (n = 4). CONCLUSIONS Verticalization is an effective noninvasive intervention for lowering ICP in intracranial hypertension that is refractory to aggressive standard management and warrants further study.
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Affiliation(s)
- Brittany Bolduc Lachance
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
| | - WanTsu Chang
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Melissa Motta
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Gunjan Parikh
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Jamie Podell
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Neeraj Badjatia
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Gary T Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Nicholas A Morris
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
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12
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van der Worp HB, Hofmeijer J, Jüttler E, Lal A, Michel P, Santalucia P, Schönenberger S, Steiner T, Thomalla G. European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction. Eur Stroke J 2021; 6:XC-CX. [PMID: 34414308 PMCID: PMC8370072 DOI: 10.1177/23969873211014112] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/13/2021] [Indexed: 01/29/2023] Open
Abstract
Space-occupying brain oedema is a potentially life-threatening complication in the first days after large hemispheric or cerebellar infarction. Several treatment strategies for this complication are available, but the size and quality of the scientific evidence on which these strategies are based vary considerably. The aim of this Guideline document is to assist physicians in their management decisions when treating patients with space-occupying hemispheric or cerebellar infarction. These Guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A working group identified 13 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. An expert consensus statement was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high-quality evidence to recommend surgical decompression to reduce the risk of death and to increase the chance of a favourable outcome in adult patients aged up to and including 60 years with space-occupying hemispheric infarction who can be treated within 48 hours of stroke onset, and low-quality evidence to support this treatment in older patients. There is continued uncertainty about the benefit and risks of surgical decompression in patients with space-occupying hemispheric infarction if this is done after the first 48 hours. There is also continued uncertainty about the selection of patients with space-occupying cerebellar infarction for surgical decompression or drainage of cerebrospinal fluid. These Guidelines further provide details on the management of specific subgroups of patients with space-occupying hemispheric infarction, on the value of monitoring of intracranial pressure, and on the benefits and risks of medical treatment options. We encourage new high-quality studies assessing the risks and benefits of different treatment strategies for patients with space-occupying brain infarction.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
| | - Eric Jüttler
- Department of Neurology, Kliniken Ostalb, Aalen, Germany
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Patrik Michel
- Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques CHUV, Lausanne, Switzerland
| | - Paola Santalucia
- Neurology-Stroke Unit, San Giuseppe Hospital-Multimedica, Milan, Italy
| | | | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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13
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Ou M, Fan W, Sun F, Li M, Lin M, Yu Y, Liang S, Liao H, Jie W, Cai Y, Chen F, Chen X, Zhao T, Tang P, Cui L, Zhou H. Nasal Delivery of AntagomiR-741 Protects Against the Radiation-Induced Brain Injury in Mice. Radiat Res 2021; 195:355-365. [PMID: 33544844 DOI: 10.1667/rade-20-00070.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 12/09/2020] [Indexed: 11/03/2022]
Abstract
Radiation-induced brain injury (RBI) is a serious complication in patients who have received radiotherapy for head and neck tumors. Currently, there is a scarcity of information on early diagnostic and preventive methods of RBI. Accumulating evidence suggests that microRNAs are involved in the regulation of radiation injury, but the molecular biological mechanism of miRNAs in RBI is largely unknown. Therefore, in our study, microRNA sequencing was used to discover differential miRNAs in the hippocampus of RBI-modeled mice, which suggested that miR-741-3p was most significantly upregulated. To clarify the underlying mechanism of miR-741-3p in RBI-modeled mice, an inhibitor of miR-741-3p (antagomiR-741) was delivered into the brain via the nasal passage before irradiation. The delivery of antagomiR-741 significantly reduced miR-741-3p levels in the hippocampus of RBI-modeled mice, and the cognitive dysfunction and neuronal apoptosis induced by radiation were also alleviated at 6 weeks postirradiation. Downregulation of miR-741-3p was found to improve the protrusion and branching status of microglia after irradiation and reduced the number of GFAP-positive astrocytes. Additionally, antagomiR-741 suppressed the radiation-induced production of pro-inflammatory cytokines IL-6 and TNF-α in the hippocampus and S100B in the serum. Furthermore, Ddr2, PKCα and St8sia1 were revealed as target genes of miR-741-3p and as potential regulatory targets for RBI. Overall, our study provides identification and functional evaluation of miRNA in RBI and lays the foundation for improving the prevention strategy for RBI based on the delivery of miRNA via the nose-brain pathway.
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Affiliation(s)
- Mingqian Ou
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.,Department of Neurology, Luoding People's Hospital, Affiliated Hospital of Guangdong Medical University, Luoding, China
| | - Weihao Fan
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.,Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Furong Sun
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.,Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Minhua Li
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Meijun Lin
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Yangsheng Yu
- Department of Neurology, Puning People's Hospital, Southern Medical University, Jieyang, China
| | - Shiyun Liang
- Department of Otorhinolaryngology, Luoding People's Hospital, Affiliated Hospital of Guangdong Medical University, Luoding, China
| | - Haojie Liao
- Department of Neurology, Southern Medical University, Affiliated Shenzhen Bao An Hospital, Shenzhen, China
| | - Wanxin Jie
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Yujie Cai
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.,Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Feng Chen
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.,Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Xiongjin Chen
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.,Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Tian Zhao
- The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Pei Tang
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Lili Cui
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.,Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Haihong Zhou
- Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, The Intensive Care Unit, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.,Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
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14
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Yamakawa Y, Morioka M, Negoto T, Orito K, Yoshitomi M, Nakamura Y, Takeshige N, Yamamoto M, Takeuchi Y, Oda K, Jono H, Saito H. A novel step-down infusion method of barbiturate therapy: Its safety and effectiveness for intracranial pressure control. Pharmacol Res Perspect 2021; 9:e00719. [PMID: 33617150 PMCID: PMC7899213 DOI: 10.1002/prp2.719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/22/2020] [Indexed: 11/28/2022] Open
Abstract
Intracranial pressure (ICP) has to be maintained quite constant, because increased ICP caused by cerebrovascular disease and head trauma is fatal. Although controlling ICP is clinically critical, only few therapeutic methods are currently available. Barbiturates, a group of sedative-hypnotic drugs, are recognized as secondary treatment for controlling ICP. We proposed a novel "step-down infusion" method, administrating barbiturate (thiamylal) after different time point from the start of treatment under normothermia, at doses of 3.0 (0-24 h), 2.0 (24-48 h), 1.5 (48-72 h), and 1.0 mg/kg/h (72-96 h), and evaluated its safety and effectiveness in clinical. In 22 patients with severe traumatic brain injury or severe cerebrovascular disease (Glasgow coma scale ≤8), thiamylal concentrations and ICP were monitored. The step-down infusion method under normothermia maintained stable thiamylal concentrations (<26.1 µg/ml) without any abnormal accumulation/elevation, and could successfully keep ICP <20 mmHg (targeted management value: ICP <20 mmHg) in all patients. Moreover the mean value of cerebral perfusion pressure (CPP) was also maintained over 65 mmHg during all time course (targeted management value: CPP >65 mmHg), and no threatening changes in serum potassium or any hemodynamic instability were observed. Our novel "step-down infusion" method under normothermia enabled to maintain stable, safe thiamylal concentrations to ensure both ICP reduction and CPP maintenance without any serious side effects, may provide a novel and clinically effective treatment option for patients with increased ICP.
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Affiliation(s)
- Yukako Yamakawa
- Department of PharmacyKumamoto University HospitalKumamotoJapan
| | - Motohiro Morioka
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Tetsuya Negoto
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Kimihiko Orito
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Munetake Yoshitomi
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Yukihiko Nakamura
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Nobuyuki Takeshige
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Masafumi Yamamoto
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Yasuharu Takeuchi
- Departments of NeurosurgeryKurume University School of MedicineFukuokaJapan
| | - Kazutaka Oda
- Department of PharmacyKumamoto University HospitalKumamotoJapan
| | - Hirofumi Jono
- Department of PharmacyKumamoto University HospitalKumamotoJapan
| | - Hideyuki Saito
- Department of PharmacyKumamoto University HospitalKumamotoJapan
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15
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Huijben JA, Dixit A, Stocchetti N, Maas AIR, Lingsma HF, van der Jagt M, Nelson D, Citerio G, Wilson L, Menon DK, Ercole A. Use and impact of high intensity treatments in patients with traumatic brain injury across Europe: a CENTER-TBI analysis. Crit Care 2021; 25:78. [PMID: 33622371 PMCID: PMC7901510 DOI: 10.1186/s13054-020-03370-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/03/2020] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To study variation in, and clinical impact of high Therapy Intensity Level (TIL) treatments for elevated intracranial pressure (ICP) in patients with traumatic brain injury (TBI) across European Intensive Care Units (ICUs). METHODS We studied high TIL treatments (metabolic suppression, hypothermia (< 35 °C), intensive hyperventilation (PaCO2 < 4 kPa), and secondary decompressive craniectomy) in patients receiving ICP monitoring in the ICU stratum of the CENTER-TBI study. A random effect logistic regression model was used to determine between-centre variation in their use. A propensity score-matched model was used to study the impact on outcome (6-months Glasgow Outcome Score-extended (GOSE)), whilst adjusting for case-mix severity, signs of brain herniation on imaging, and ICP. RESULTS 313 of 758 patients from 52 European centres (41%) received at least one high TIL treatment with significant variation between centres (median odds ratio = 2.26). Patients often transiently received high TIL therapies without escalation from lower tier treatments. 38% of patients with high TIL treatment had favourable outcomes (GOSE ≥ 5). The use of high TIL treatment was not significantly associated with worse outcome (285 matched pairs, OR 1.4, 95% CI [1.0-2.0]). However, a sensitivity analysis excluding high TIL treatments at day 1 or use of metabolic suppression at any day did reveal a statistically significant association with worse outcome. CONCLUSION Substantial between-centre variation in use of high TIL treatments for TBI was found and treatment escalation to higher TIL treatments were often not preceded by more conventional lower TIL treatments. The significant association between high TIL treatments after day 1 and worse outcomes may reflect aggressive use or unmeasured confounders or inappropriate escalation strategies. TAKE HOME MESSAGE Substantial variation was found in the use of highly intensive ICP-lowering treatments across European ICUs and a stepwise escalation strategy from lower to higher intensity level therapy is often lacking. Further research is necessary to study the impact of high therapy intensity treatments. TRIAL REGISTRATION The core study was registered with ClinicalTrials.gov, number NCT02210221, registered 08/06/2014, https://clinicaltrials.gov/ct2/show/NCT02210221?id=NCT02210221&draw=1&rank=1 and with Resource Identification Portal (RRID: SCR_015582).
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Affiliation(s)
- Jilske A Huijben
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Abhishek Dixit
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
- Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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16
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Velle F, Lewén A, Howells T, Nilsson P, Enblad P. Temporal effects of barbiturate coma on intracranial pressure and compensatory reserve in children with traumatic brain injury. Acta Neurochir (Wien) 2021; 163:489-498. [PMID: 33341913 PMCID: PMC7815615 DOI: 10.1007/s00701-020-04677-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/07/2020] [Indexed: 01/18/2023]
Abstract
Background The aim was to study the effects of barbiturate coma treatment (BCT) on intracranial pressure (ICP) and intracranial compensatory reserve (RAP index) in children (< 17 years of age) with traumatic brain injury (TBI) and refractory intracranial hypertension (RICH). Methods High-resolution monitoring data were used to study the effects of BCT on ICP, mean arterial pressure (MAP), cerebral perfusion pressure (CPP), and RAP index. Four half hour long periods were studied: before bolus injection and at 5, 10, and 24 hours thereafter, respectively, and a fifth tapering period with S-thiopental between < 100 and < 30 μmol/L. S-thiopental concentrations and administered doses were registered. Results Seventeen children treated with BCT 2007–2017 with high-resolution data were included; median age 15 (range 6–17) and median Glasgow coma score 7 (range 3–8). Median time from trauma to start of BCT was 44.5 h (range 2.5–197.5) and from start to stop 99.0 h (range 21.0–329.0). Median ICP was 22 (IQR 20–25) in the half hour period before onset of BCT and 16 (IQR 11–20) in the half hour period 5 h later (p = 0.011). The corresponding figures for CPP were 65 (IQR 62–71) and 63 (57–71) (p > 0.05). The RAP index was in the half hour period before onset of BCT 0.6 (IQR 0.1–0.7), in the half hour period 5 h later 0.3 (IQR 0.1–0.7) (p = 0.331), and in the whole BCT period 0.3 (IQR 0.2–0.4) (p = 0.004). Eighty-two percent (14/17) had favorable outcome (good recovery = 8 patients and moderate disability = 6 patients). Conclusion BCT significantly reduced ICP and RAP index with preserved CPP. BCT should be considered in case of RICH.
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Affiliation(s)
- Fartein Velle
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE 751 85, Uppsala, Sweden.
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE 751 85, Uppsala, Sweden
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE 751 85, Uppsala, Sweden
| | - Pelle Nilsson
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE 751 85, Uppsala, Sweden
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17
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Roberson SW, Patel MB, Dabrowski W, Ely EW, Pakulski C, Kotfis K. Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice. Curr Neuropharmacol 2021; 19:1519-1544. [PMID: 33463474 PMCID: PMC8762177 DOI: 10.2174/1570159x19666210119153839] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/12/2020] [Accepted: 01/13/2021] [Indexed: 11/22/2022] Open
Abstract
Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.
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Affiliation(s)
| | | | | | | | | | - Katarzyna Kotfis
- Address correspondence to this author at the Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland; E-mail:
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18
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Battaglini D, Anania P, Rocco PRM, Brunetti I, Prior A, Zona G, Pelosi P, Fiaschi P. Escalate and De-Escalate Therapies for Intracranial Pressure Control in Traumatic Brain Injury. Front Neurol 2020; 11:564751. [PMID: 33324317 PMCID: PMC7724991 DOI: 10.3389/fneur.2020.564751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/30/2020] [Indexed: 12/22/2022] Open
Abstract
Severe traumatic brain injury (TBI) is frequently associated with an elevation of intracranial pressure (ICP), followed by cerebral perfusion pressure (CPP) reduction. Invasive monitoring of ICP is recommended to guide a step-by-step “staircase approach” which aims to normalize ICP values and reduce the risks of secondary damage. However, if such monitoring is not available clinical examination and radiological criteria should be used. A major concern is how to taper the therapies employed for ICP control. The aim of this manuscript is to review the criteria for escalating and withdrawing therapies in TBI patients. Each step of the staircase approach carries a risk of adverse effects related to the duration of treatment. Tapering of barbiturates should start once ICP control has been achieved for at least 24 h, although a period of 2–12 days is often required. Administration of hyperosmolar fluids should be avoided if ICP is normal. Sedation should be reduced after at least 24 h of controlled ICP to allow neurological examination. Removal of invasive ICP monitoring is suggested after 72 h of normal ICP. For patients who have undergone surgical decompression, cranioplasty represents the final step, and an earlier cranioplasty (15–90 days after decompression) seems to reduce the rate of infection, seizures, and hydrocephalus.
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Affiliation(s)
- Denise Battaglini
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Pasquale Anania
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil.,Rio de Janeiro Innovation Network in Nanosystems for Health-Nano SAÚDE/Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Iole Brunetti
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Alessandro Prior
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integral Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Pietro Fiaschi
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
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19
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Anania P, Battaglini D, Miller JP, Balestrino A, Prior A, D'Andrea A, Badaloni F, Pelosi P, Robba C, Zona G, Fiaschi P. Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary? Neurosurg Rev 2020; 44:2415-2423. [PMID: 33215367 PMCID: PMC7676754 DOI: 10.1007/s10143-020-01438-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/29/2020] [Accepted: 11/11/2020] [Indexed: 11/24/2022]
Abstract
Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.
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Affiliation(s)
- Pasquale Anania
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - John P Miller
- Louisiana State University, Health Sciences University, New Orleans, LA, USA
| | - Alberto Balestrino
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Alessandro Prior
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Alessandro D'Andrea
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Filippo Badaloni
- Division of Neurosurgery, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy
| | - Pietro Fiaschi
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy
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20
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Lobo FA, Vacas S, Rossetti AO, Robba C, Taccone FS. Does electroencephalographic burst suppression still play a role in the perioperative setting? Best Pract Res Clin Anaesthesiol 2020; 35:159-169. [PMID: 34030801 DOI: 10.1016/j.bpa.2020.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/21/2020] [Accepted: 10/27/2020] [Indexed: 12/18/2022]
Abstract
With the widespread use of electroencephalogram [EEG] monitoring during surgery or in the Intensive Care Unit [ICU], clinicians can sometimes face the pattern of burst suppression [BS]. The BS pattern corresponds to the continuous quasi-periodic alternation between high-voltage slow waves [the bursts] and periods of low voltage or even isoelectricity of the EEG signal [the suppression] and is extremely rare outside ICU and the operative room. BS can be secondary to increased anesthetic depth or a marker of cerebral damage, as a therapeutic endpoint [i.e., refractory status epilepticus or refractory intracranial hypertension]. In this review, we report the neurophysiological features of BS to better define its role during intraoperative and critical care settings.
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Affiliation(s)
- Francisco Almeida Lobo
- Anesthesiology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, Lordelo, 5000-508, Vila Real, Portugal.
| | - Susana Vacas
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Reagan UCLA Medical Center, 757 Westwood Plaza #3325, Los Angeles, CA, 90095, USA.
| | - Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital and University of Lausanne, CH-1011, Lausanne, Switzerland.
| | - Chiara Robba
- Azienda Ospedaliera Universitaria San Martino di Genova, Largo Rosanna Benzi,15, 16100, Genova, Italy.
| | - Fabio Silvio Taccone
- Hopital Érasme, Université Libre de Bruxelles, Department of Intensive Care Medicine, Route de Lennik, 808 1070, Brussels, Belgium.
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21
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Schizodimos T, Soulountsi V, Iasonidou C, Kapravelos N. An overview of management of intracranial hypertension in the intensive care unit. J Anesth 2020; 34:741-757. [PMID: 32440802 PMCID: PMC7241587 DOI: 10.1007/s00540-020-02795-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 05/09/2020] [Indexed: 12/29/2022]
Abstract
Intracranial hypertension (IH) is a clinical condition commonly encountered in the intensive care unit, which requires immediate treatment. The maintenance of normal intracranial pressure (ICP) and cerebral perfusion pressure in order to prevent secondary brain injury (SBI) is the central focus of management. SBI can be detected through clinical examination and invasive and non-invasive ICP monitoring. Progress in monitoring and understanding the pathophysiological mechanisms of IH allows the implementation of targeted interventions in order to improve the outcome of these patients. Initially, general prophylactic measures such as patient's head elevation, fever control, adequate analgesia and sedation depth should be applied immediately to all patients with suspected IH. Based on specific indications and conditions, surgical resection of mass lesions and cerebrospinal fluid drainage should be considered as an initial treatment for lowering ICP. Hyperosmolar therapy (mannitol or hypertonic saline) represents the cornerstone of medical treatment of acute IH while hyperventilation should be limited to emergency management of life-threatening raised ICP. Therapeutic hypothermia could have a possible benefit on outcome. To control elevated ICP refractory to maximum standard medical and surgical treatment, at first, high-dose barbiturate administration and then decompressive craniectomy as a last step are recommended with unclear and probable benefit on outcomes, respectively. The therapeutic strategy should be based on a staircase approach and be individualized for each patient. Since most therapeutic interventions have an uncertain effect on neurological outcome and mortality, future research should focus on both studying the long-term benefits of current strategies and developing new ones.
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Affiliation(s)
- Theodoros Schizodimos
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, G. Papanikolaou Avenue, 57010, Exochi, Thessaloniki, Greece.
| | - Vasiliki Soulountsi
- 1st Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
| | - Christina Iasonidou
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, G. Papanikolaou Avenue, 57010, Exochi, Thessaloniki, Greece
| | - Nikos Kapravelos
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, G. Papanikolaou Avenue, 57010, Exochi, Thessaloniki, Greece
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Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD003983. [PMID: 31887790 PMCID: PMC6953357 DOI: 10.1002/14651858.cd003983.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy). OBJECTIVES To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH METHODS The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts. SELECTION CRITERIA We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care. DATA COLLECTION AND ANALYSIS We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach. MAIN RESULTS We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events. AUTHORS' CONCLUSIONS Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.
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Affiliation(s)
- Juan Sahuquillo
- Vall d'Hebron University HospitalDepartment of NeurosurgeryUniversitat Autònoma de BarcelonaPaseo Vall d'Hebron 119 ‐ 129BarcelonaBarcelonaSpain08035
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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Larson CM, Wilcox GL, Fairbanks CA. Defining and Managing Pain in Stroke and Traumatic Brain Injury Research. Comp Med 2019; 69:510-519. [PMID: 31896392 PMCID: PMC6935700 DOI: 10.30802/aalas-cm-19-000099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/07/2019] [Accepted: 11/27/2019] [Indexed: 01/01/2023]
Abstract
Neurologic conditions such as stroke and traumatic brain injury are challenging conditions to study in humans. Animal models are necessary to uncover disease processes and develop novel therapies. When attempting to model these or other neurologic diseases, the accompanying anesthesia and analgesia create variables that are not part of the onset of the clinical disease in the human population but are critical components of the postinjury care both in humans and animals. To maximize model validity, researchers must consider whether the disease process or a novel therapy is being studied. Damage to the neurons of the brain or the spinal cord is not painful at the neural tissue itself, but alterations to nociceptive signaling along the pain pathway can induce chronic pain. In addition, trauma or surgery leading to the event is associated with damage to peripheral tissue. Inflammation is inextricably associated with tissue injury. Inflammation is known to evoke nociception in the periphery and drive long-term changes to neurons in the CNS. Analgesics and anesthetics alter these responses yet are required as part of humane animal care. Careful planning for effective drug administration consistent with the standard of care for humans and equivalent animal care is required.
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Affiliation(s)
- Christina M Larson
- Departments of Comparative and Molecular Biosciences, University of Minnesota College of Veterinary Medicine, St Paul, Minnesota;,
| | - George L Wilcox
- Departments of Neuroscience, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Carolyn A Fairbanks
- Departments of Pharmacology, University of Minnesota Medical School, Minneapolis, Minnesota
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Halstead MR, Geocadin RG. The Medical Management of Cerebral Edema: Past, Present, and Future Therapies. Neurotherapeutics 2019; 16:1133-1148. [PMID: 31512062 PMCID: PMC6985348 DOI: 10.1007/s13311-019-00779-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Cerebral edema is commonly associated with cerebral pathology, and the clinical manifestation is largely related to the underlying lesioned tissue. Brain edema usually amplifies the dysfunction of the lesioned tissue and the burden of cerebral edema correlates with increased morbidity and mortality across diseases. Our modern-day approach to the medical management of cerebral edema has largely revolved around, an increasingly artificial distinction between cytotoxic and vasogenic cerebral edema. These nontargeted interventions such as hyperosmolar agents and sedation have been the mainstay in clinical practice and offer noneloquent solutions to a dire problem. Our current understanding of the underlying molecular mechanisms driving cerebral edema is becoming much more advanced, with differences being identified across diseases and populations. As our understanding of the underlying molecular mechanisms in neuronal injury continues to expand, so too is the list of targeted therapies in the pipeline. Here we present a brief review of the molecular mechanisms driving cerebral edema and a current overview of our understanding of the molecular targets being investigated.
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Affiliation(s)
- Michael R Halstead
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology-Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA.
| | - Romergryko G Geocadin
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology-Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA
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25
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Gonschorek AS, Schaan M, Schwenkreis P, Wohlfarth K, Schmehl I. [Quality standards in treatment and rehabilitation of traumatic brain injuries]. Chirurg 2019; 89:1017-1032. [PMID: 30377703 DOI: 10.1007/s00104-018-0751-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The quality standards of the "Deutsche gesetzliche Unfallversicherung" (DGUV) on the treatment of traumatic brain injuries were first published in 2015. They describe the optimal conditions and requirements of acute treatment and in all phases of rehabilitation and aftercare, according to the current state of knowledge. The aim is to enable a life worth living in family, school, occupation and society for as many injuries as possible. The quality standards, as systematic orientation and decision-making aids, should promote the future development of the treatment and rehabilitation of traumatic brain injuries of all grades of severity and guarantee a uniformly high quality of treatment. A special and comprehensive rehabilitative alignment as well as a close networking of medical and occupation-promoting services will be of particular importance for the institutions participating in the rehabilitation of patients with traumatic brain injuries.
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Affiliation(s)
- A S Gonschorek
- Neurotraumatologisches Zentrum, BG Klinikum Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Deutschland.
| | - M Schaan
- BG Unfallklinik Murnau, Murnau, Deutschland
| | - P Schwenkreis
- BG Universitätsklinikum Bergmannsheil Bochum, Bochum, Deutschland
| | - K Wohlfarth
- BG Klinikum Bergmannstrost Halle, Halle, Deutschland
| | - I Schmehl
- BG Klinikum Unfallkrankenhaus Berlin, Berlin, Deutschland
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26
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Wang L, Ma S, Hu Z, McGuire TF, Xie XQ(S. Chemogenomics Systems Pharmacology Mapping of Potential Drug Targets for Treatment of Traumatic Brain Injury. J Neurotrauma 2019; 36:565-575. [PMID: 30014763 PMCID: PMC6354609 DOI: 10.1089/neu.2018.5757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Traumatic brain injury (TBI) is associated with high mortality and morbidity. Though the death rate of initial trauma has dramatically decreased, no drug has been developed to effectively limit the progression of the secondary injury caused by TBI. TBI appears to be a predisposing risk factor for Alzheimer's disease (AD), whereas the molecular mechanisms remain unknown. In this study, we have conducted a research investigation of computational chemogenomics systems pharmacology (CSP) to identify potential drug targets for TBI treatment. TBI-induced transcriptional profiles were compared with those induced by genetic or chemical perturbations, including drugs in clinical trials for TBI treatment. The protein-protein interaction network of these predicted targets were then generated for further analyses. Some protein targets when perturbed, exhibit inverse transcriptional profiles in comparison with the profiles induced by TBI, and they were recognized as potential therapeutic targets for TBI. Drugs acting on these targets are predicted to have the potential for TBI treatment if they can reverse the TBI-induced transcriptional profiles that lead to secondary injury. In particular, our results indicated that TRPV4, NEUROD1, and HPRT1 were among the top therapeutic target candidates for TBI, which are congruent with literature reports. Our analyses also suggested the strong associations between TBI and AD, as perturbations on AD-related genes, such as APOE, APP, PSEN1, and MAPT, can induce similar gene expression patterns as those of TBI. To the best of our knowledge, this is the first CSP-based gene expression profile analyses for predicting TBI-related drug targets, and the findings could be used to guide the design of new drugs targeting the secondary injury caused by TBI.
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Affiliation(s)
- Lirong Wang
- Department of Pharmaceutical Sciences and Computational Chemical Genomics Screening Center, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
- NIH National Center of Excellence for Computational Drug Abuse Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shifan Ma
- Department of Pharmaceutical Sciences and Computational Chemical Genomics Screening Center, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
- NIH National Center of Excellence for Computational Drug Abuse Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ziheng Hu
- Department of Pharmaceutical Sciences and Computational Chemical Genomics Screening Center, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
- NIH National Center of Excellence for Computational Drug Abuse Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Terence Francis McGuire
- Department of Pharmaceutical Sciences and Computational Chemical Genomics Screening Center, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
- NIH National Center of Excellence for Computational Drug Abuse Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xiang-Qun (Sean) Xie
- Department of Pharmaceutical Sciences and Computational Chemical Genomics Screening Center, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
- NIH National Center of Excellence for Computational Drug Abuse Research, University of Pittsburgh, Pittsburgh, Pennsylvania
- Drug Discovery Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
- Departments of Computational Biology and Structural Biology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Panahi Y, Mojtahedzadeh M, Najafi A, Rajaee SM, Torkaman M, Sahebkar A. Neuroprotective Agents in the Intensive Care Unit: -Neuroprotective Agents in ICU. J Pharmacopuncture 2018; 21:226-240. [PMID: 30652049 PMCID: PMC6333194 DOI: 10.3831/kpi.2018.21.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 08/09/2018] [Accepted: 11/14/2018] [Indexed: 01/31/2023] Open
Abstract
Neuroprotection or prevention of neuronal loss is a complicated molecular process that is mediated by various cellular pathways. Use of different pharmacological agents as neuroprotectants has been reported especially in the last decades. These neuroprotective agents act through inhibition of inflammatory processes and apoptosis, attenuation of oxidative stress and reduction of free radicals. Control of this injurious molecular process is essential to the reduction of neuronal injuries and is associated with improved functional outcomes and recovery of the patients admitted to the intensive care unit. This study reviews neuroprotective agents and their mechanisms of action against central nervous system damages.
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Affiliation(s)
- Yunes Panahi
- Clinical Pharmacy Department, Faculty of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran,
Iran
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran,
Iran
| | - Mojtaba Mojtahedzadeh
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran,
Iran
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran,
Iran
| | - Atabak Najafi
- Gastrointestinal Pharmacology Interest Group(GPIG), Universal Scientific Education and Research Network(USERN), Tehran,
Iran
| | - Seyyed Mahdi Rajaee
- Gastrointestinal Pharmacology Interest Group(GPIG), Universal Scientific Education and Research Network(USERN), Tehran,
Iran
| | - Mohammad Torkaman
- Department of Pediatrics, School of Medicine, Baqiyatallah University of Medical Sciences, Tehran,
Iran
| | - Amirhossein Sahebkar
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad,
Iran
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad,
Iran
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad,
Iran
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Firsching R. Coma After Acute Head Injury. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:313-320. [PMID: 28587706 DOI: 10.3238/arztebl.2017.0313] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/22/2016] [Accepted: 02/16/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Coma after acute head injury is always alarming. Depending on the type of injury, immediate treatment may be life-saving. About a quarter of a million patients are treated for traumatic brain injury in Germany each year. Treatment recommendations must be updated continually in the light of advancing knowledge. METHODS This review of treatment recommendations, prognostic factors, and the pathophysiology of coma after acute head injury is based on a 2015 German guideline for the treatment of head injury in adults and on pertinent publications retrieved by a selective search in PubMed for literature on post-traumatic coma. RESULTS As soon as the vital functions have been secured, patients with acute head injury should undergo cranial computed tomography, which is the method of choice for identifying intracranial injuries needing immediate treatment. Patients who have an intracranial hematoma with mass effect should be taken to surgery at once. The prognosis is significantly correlated with the patient's age, the duration of coma, accompanying neurological manifestations, and the site of brain injury. The case fatality rate of patients who have been comatose for 24 hours and who have accompanying lateralizing signs, a unilaterally absent pupillary light reflex, or hemiparesis lies between 30% and 50%. This figure rises to 50-60% in patients with abnormal extensor reflexes and to over 90% in those with bilaterally absent pupillary light reflexes. Current neuropathological and neuroradiological studies indicate that coma after acute head injury is due to reversible or irreversible dysfunction of the brainstem. CONCLUSION Brain tissue can tolerate ischemia and elevated pressure only for a very limited time. Comatose head-injured patients must therefore be evaluated urgently to determine whether they can be helped by the surgical removal of a hematoma or by a decompressive hemicraniectomy.
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Synnot A, Bragge P, Lunny C, Menon D, Clavisi O, Pattuwage L, Volovici V, Mondello S, Cnossen MC, Donoghue E, Gruen RL, Maas A. The currency, completeness and quality of systematic reviews of acute management of moderate to severe traumatic brain injury: A comprehensive evidence map. PLoS One 2018; 13:e0198676. [PMID: 29927963 PMCID: PMC6013193 DOI: 10.1371/journal.pone.0198676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/23/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To appraise the currency, completeness and quality of evidence from systematic reviews (SRs) of acute management of moderate to severe traumatic brain injury (TBI). METHODS We conducted comprehensive searches to March 2016 for published, English-language SRs and RCTs of acute management of moderate to severe TBI. Systematic reviews and RCTs were grouped under 12 broad intervention categories. For each review, we mapped the included and non-included RCTs, noting the reasons why RCTs were omitted. An SR was judged as 'current' when it included the most recently published RCT we found on their topic, and 'complete' when it included every RCT we found that met its inclusion criteria, taking account of when the review was conducted. Quality was assessed using the AMSTAR checklist (trichotomised into low, moderate and high quality). FINDINGS We included 85 SRs and 213 RCTs examining the effectiveness of treatments for acute management of moderate to severe TBI. The most frequently reviewed interventions were hypothermia (n = 17, 14.2%), hypertonic saline and/or mannitol (n = 9, 7.5%) and surgery (n = 8, 6.7%). Of the 80 single-intervention SRs, approximately half (n = 44, 55%) were judged as current and two-thirds (n = 52, 65.0%) as complete. When considering only the most recently published review on each intervention (n = 25), currency increased to 72.0% (n = 18). Less than half of the 85 SRs were judged as high quality (n = 38, 44.7%), and nearly 20% were low quality (n = 16, 18.8%). Only 16 (20.0%) of the single-intervention reviews (and none of the five multi-intervention reviews) were judged as current, complete and high-quality. These included reviews of red blood cell transfusion, hypothermia, management guided by intracranial pressure, pharmacological agents (various) and prehospital intubation. Over three-quarters (n = 167, 78.4%) of the 213 RCTs were included in one or more SR. Of the remainder, 17 (8.0%) RCTs post-dated or were out of scope of existing SRs, and 29 (13.6%) were on interventions that have not been assessed in SRs. CONCLUSION A substantial number of SRs in acute management of moderate to severe TBI lack currency, completeness and quality. We have identified both potential evidence gaps and also substantial research waste. Novel review methods, such as Living Systematic Reviews, may ameliorate these shortcomings and enhance utility and reliability of the evidence underpinning clinical care.
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Affiliation(s)
- Anneliese Synnot
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cochrane Consumers and Communication, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Carole Lunny
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Menon
- Division of Anaesthesia, University of Cambridge; Neurosciences Critical Care Unit, Addenbrooke’s Hospital; Queens’ College, Cambridge, United Kingdom
| | - Ornella Clavisi
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- MOVE: Muscle, Bone and Joint Health Ltd, Melbourne, Victoria, Australia
| | - Loyal Pattuwage
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- Monash Centre for Occupational and Environmental Health (MonCOEH), Monash University, Melbourne, Victoria, Australia
| | - Victor Volovici
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Maryse C. Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Emma Donoghue
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Russell L. Gruen
- Nanyang Technical University, Singapore
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Cui JB, Chen QQ, Liu TT, Li SJ. Risk factors for early-onset ventilator-associated pneumonia in aneurysmal subarachnoid hemorrhage patients. ACTA ACUST UNITED AC 2018; 51:e6830. [PMID: 29791584 PMCID: PMC5972009 DOI: 10.1590/1414-431x20176830] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 12/06/2017] [Indexed: 01/09/2023]
Abstract
This study aimed to investigate the risk factors related to ventilator-acquired pneumonia (VAP) in aneurysmal subarachnoid hemorrhage (SAH) patients. From January 2011 to December 2015, a single-center retrospective study including 200 SAH patients requiring mechanical ventilation (MV) ≥48 h was performed. The clinical data of these patients were collected and analyzed. The age range of the patients were 41-63 and 72 (36%) were male. The Glasgow coma scale score range was 5-15 and the Simplified Acute Physiology Score II range was 31-52. One hundred and forty-eight (74%) patients had a World Federation of Neurosurgeons (WNFS) score ≥III. Aneurysm was secured with an endovascular coiling procedure in 168 (84%) patients and 94 (47%) patients presented VAP. Male gender (OR=2.25, 95%CI=1.15-4.45), use of mannitol (OR=3.02, 95%CI=1.53-5.94) and enteral feeding above 20 kcal·kg-1·day-1 (OR=2.90, 95%CI=1.26-6.67) after day 7 were independent factors for VAP. Patients with early-onset VAP had a longer duration of sedation (P=0.03), MV (P=0.001) and ICU length of stay (P=0.003) and a worse Glasgow Outcome Scale score (P<0.001), but did not have a higher death rate.
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Affiliation(s)
- J B Cui
- Neurosurgery Intensive Care Unit, Weifang People's Hospital, Weifang, China
| | - Q Q Chen
- Neurosurgery Intensive Care Unit, Weifang People's Hospital, Weifang, China
| | - T T Liu
- Neurosurgery Intensive Care Unit, Weifang People's Hospital, Weifang, China
| | - S J Li
- Neurosurgery Intensive Care Unit, Weifang People's Hospital, Weifang, China
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Dumps C, Halbeck E, Bolkenius D. Medikamente zur intravenösen Narkoseinduktion: Barbiturate. Anaesthesist 2018; 67:535-552. [DOI: 10.1007/s00101-018-0440-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability in patients with trauma. Management strategies must focus on preventing secondary injury by avoiding hypotension and hypoxia and maintaining appropriate cerebral perfusion pressure (CPP), which is a surrogate for cerebral blood flow. CPP can be maintained by increasing mean arterial pressure, decreasing intracranial pressure, or both. The goal should be euvolemia and avoidance of hypotension. Other factors that deserve important consideration in the acute management of patients with TBI are venous thromboembolism, stress ulcer, and seizure prophylaxis, as well as nutritional and metabolic optimization.
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Affiliation(s)
- Michael A. Vella
- Chief Resident in General Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Medical Center North, CCC-4312, 1161 21st Avenue South, Nashville, TN 37232-2730,
| | - Marie Crandall
- Professor of Surgery, Division of Acute Care Surgery, Department of Surgery, University of Florida, Jacksonville, 655 West 8th Street, Jacksonville, FL 32209,
| | - Mayur B. Patel
- Assistant Professor of Surgery, Neurosurgery, Hearing & Speech Sciences, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Section of Surgical Sciences, Center for Health Services Research, Vanderbilt Brain Institute, Vanderbilt University Medical Center, 1211 21 Avenue South, Medical Arts Building, Suite 404, Nashville, TN 37212,
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Varghese R, Chakrabarty J, Menon G. Nursing Management of Adults with Severe Traumatic Brain Injury: A Narrative Review. Indian J Crit Care Med 2017; 21:684-697. [PMID: 29142381 PMCID: PMC5672675 DOI: 10.4103/ijccm.ijccm_233_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Effective nursing management strategies for adults with severe traumatic brain injury (STBI) are still a remarkable issue and a difficult task for neurologists, neurosurgeons, and neuronurses. A list of justified indications and scientific rationale for nursing management of these patients are continuously evolving. The objectives of the study are to analyze the pertinently available research and clinical studies that demonstrate the nursing management strategies for adults with STBI and to synthesize the available evidence based on the review. A comprehensive literature search was made in following databases such as Google Scholar, Cochrane, J-Gate, ProQuest, and ScienceDirect for retrieving the related studies. In the included studies, data were extracted and evaluated according to the objective. Narrative analysis was adopted to write this review. Patients with STBI have poor prognosis and require quality care for maximizing patients' survival. With a thorough knowledge and discernment of care of such patients, nurses can improve these patients' neurological outcomes.
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Affiliation(s)
| | - Jyothi Chakrabarty
- Department of Medical Surgical Nursing, Manipal College of Nursing, Manipal, Karnataka, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Hospital, Manipal, Karnataka, India
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Sorby-Adams AJ, Marcoionni AM, Dempsey ER, Woenig JA, Turner RJ. The Role of Neurogenic Inflammation in Blood-Brain Barrier Disruption and Development of Cerebral Oedema Following Acute Central Nervous System (CNS) Injury. Int J Mol Sci 2017; 18:E1788. [PMID: 28817088 PMCID: PMC5578176 DOI: 10.3390/ijms18081788] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/07/2017] [Accepted: 08/15/2017] [Indexed: 12/13/2022] Open
Abstract
Acute central nervous system (CNS) injury, encompassing traumatic brain injury (TBI) and stroke, accounts for a significant burden of morbidity and mortality worldwide, largely attributable to the development of cerebral oedema and elevated intracranial pressure (ICP). Despite this, clinical treatments are limited and new therapies are urgently required to improve patient outcomes and survival. Originally characterised in peripheral tissues, such as the skin and lungs as a neurally-elicited inflammatory process that contributes to increased microvascular permeability and tissue swelling, neurogenic inflammation has now been described in acute injury to the brain where it may play a key role in the secondary injury cascades that evolve following both TBI and stroke. In particular, release of the neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) appear to be critically involved. In particular, increased SP expression is observed in perivascular tissue following acute CNS injury, with the magnitude of SP release being related to both the frequency and degree of the insult. SP release is associated with profound blood-brain barrier disruption and the subsequent development of vasogenic oedema, as well as neuronal injury and poor functional outcomes. Inhibition of SP through use of a neurokinin 1 (NK1) antagonist is highly beneficial following both TBI and ischaemic stroke in pre-clinical models. The role of CGRP is more unclear, especially with respect to TBI, with both elevations and reductions in CGRP levels reported following trauma. However, a beneficial role has been delineated in stroke, given its potent vasodilatory effects. Thus, modulating neuropeptides represents a novel therapeutic target in the treatment of cerebral oedema following acute CNS injury.
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Affiliation(s)
- Annabel J Sorby-Adams
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Amanda M Marcoionni
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Eden R Dempsey
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Joshua A Woenig
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Renée J Turner
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
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Grände PO. Critical Evaluation of the Lund Concept for Treatment of Severe Traumatic Head Injury, 25 Years after Its Introduction. Front Neurol 2017; 8:315. [PMID: 28725211 PMCID: PMC5495987 DOI: 10.3389/fneur.2017.00315] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/16/2017] [Indexed: 12/24/2022] Open
Abstract
When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles-i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain Trauma Foundation guidelines and European guidelines) were mainly based on meta-analytic approaches from clinical outcome studies and to some extent from systematic reviews. When introduced, they differed extensively from the LC. We still lack any large randomized outcome study comparing the whole concept of BTF guidelines with other guidelines including the LC. From that point of view, there is limited clinical evidence favoring any of the s-TBI guidelines used today. In principle, the LC has not been changed since its introduction. Some components of the alternative guidelines have approached those in the LC. In this review, I discuss some important principles of brain hemodynamics that have been lodestars during formulation of the LC. Aspects of ventilation, nutrition, and temperature control are also discussed. I critically evaluate the most important components of the LC 25 years after its introduction, based on hemodynamic principles and on the results of own an others experimental and human studies that have been published since then.
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Affiliation(s)
- Per-Olof Grände
- Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
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Burry L, Dryden L, Rose L, Williamson DR, Adhikari NKJ, Turgeon AF, Golan E, Dewhurst N, Fergusson DA, Hutton B, Mehta S. Sedation for moderate-to-severe traumatic brain injury in adults: a network meta-analysis. Hippokratia 2017. [DOI: 10.1002/14651858.cd012639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lisa Burry
- Mount Sinai Hospital, Leslie Dan Faculty of Pharmacy, University of Toronto; Department of Pharmacy; 600 University Avenue, Room 18-377 Toronto ON Canada M5G 1X5
| | - Lindsay Dryden
- University of Toronto; Leslie Dan Faculty of Pharmacy; 144 College Street Toronto ON Canada M5S 3M2
| | - Louise Rose
- University of Toronto; Lawrence S. Bloomberg Faculty of Nursing; 155 College St Toronto ON Canada M5T 1P8
| | - David R Williamson
- Université de Montréal / Höpital du Sacré-Coeur de Montréal; Faculty of Pharmacy / Department of Pharmacy; 5400 Gouin W Montreal QC Canada H4J 1C5
| | - Neill KJ Adhikari
- University of Toronto; Interdepartmental Division of Critical Care; 2057 Bayview Avenue Toronto ON Canada M4N 3M5
| | - Alexis F Turgeon
- CHU de Québec - Université Laval, Université Laval; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, and Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center; 1401, 18eme rue Quebec City QC Canada G1J 1Z4
| | - Eyal Golan
- University Health Network; Department of Medicine; 399 Bathurst Street, 2MCL-411J Toronto ON Canada M5S-2T8
| | - Norman Dewhurst
- St. Michaels Hospital; Department of Pharmacy; 30 Bond Street Toronto ON Canada M5B 1W8
| | - Dean A Fergusson
- Ottawa Hospital Research Institute; Clinical Epidemiology Program; 501 Smyth Road Ottawa ON Canada K1H 8L6
| | - Brian Hutton
- Ottawa Hospital Research Institute; Knowledge Synthesis Group; 501 Smyth Road Ottawa ON Canada K1H 8L6
| | - Sangeeta Mehta
- Mount Sinai Hospital, University of Toronto; Interdepartmental Division of Critical Care Medicine; 600 University Ave, Rm 1504 Toronto ON Canada M5G 1X5
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37
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Abstract
Since traumatic brain injury is the most common cause of long-term disability and death among young adults, it represents an enormous socio-economic and healthcare burden. As a consequence of the primary lesion, a perifocal brain edema develops causing an elevation of the intracranial pressure due to the limited intracranial space. This entails a reduction of the cerebral perfusion pressure and the cerebral blood flow. A cerebral perfusion deficit below the threshold for ischemia leads to further ischemic lesions and to a progression of the contusion. As the irreversible primary lesion can only be inhibited by primary prevention, the therapy of traumatic brain injury focuses on the secondary injuries. The treatment consists of surgical therapy evacuating the space-occupying intracranial lesion and conservative intensive medical care. Due to the complex pathophysiology the therapy of traumatic brain injury should be rapidly performed in a neurosurgical unit.
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38
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Takekita Y, Suwa T, Sunada N, Kawashima H, Fabbri C, Kato M, Tajika A, Kinoshita T, Furukawa TA, Serretti A. Remifentanil in electroconvulsive therapy: a systematic review and meta-analysis of randomized controlled trials. Eur Arch Psychiatry Clin Neurosci 2016; 266:703-717. [PMID: 26822480 DOI: 10.1007/s00406-016-0670-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/11/2016] [Indexed: 01/29/2023]
Abstract
In electroconvulsive therapy (ECT), remifentanil is often used concurrently with anesthetics. The objective of this study was to provide an up-to-date and comprehensive review on how the addition of remifentanil to anesthetics affects seizure duration and circulatory dynamics in mECT. We performed a meta-analysis of RCTs that investigated seizure duration and circulatory dynamics in patients treated with ECT using anesthetics alone (non-remifentanil group) and with anesthetics plus remifentanil (remifentanil group). A total of 13 RCTs (380 patients and 1024 ECT sessions) were included. The remifentanil group showed a significantly prolonged seizure duration during ECT compared to the non-remifentanil group [motor: 9 studies, SMD = 1.25, 95 % CI (0.21, 2.29), p = 0.02; electroencephalogram: 8 studies, SMD = 0.98, 95 % CI (0.14, 1.82), p = 0.02]. The maximum systolic blood pressure (SBP) was significantly reduced in the remifentanil group compared to the non-remifentanil group [7 studies, SMD = -0.36, 95 % CI (-0.65, 0.07), p = 0.02]. Substantial heterogeneity was observed for meta-analyses for seizure durations, but a pre-planned subgroup analysis revealed that seizure duration was prolonged only when the use of the anesthetic dose was reduced in the remifentanil group. The results of our study suggest that addition of remifentanil to anesthesia in ECT may lead to prolonged seizure duration when it allows the use of reduced anesthetic doses. Further, the addition of remifentanil was associated with reduced maximum SBP.
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Affiliation(s)
- Yoshiteru Takekita
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Viale Carlo Pepoli 5, 40123, Bologna, Italy. .,Department of Neuropsychiatry, Kansai Medical University, 10-15 Fumizono-cho, Moriguchi-shi, Osaka, 570-8506, Japan.
| | - Taro Suwa
- Department of Neuropsychiatry, Graduate School of Medicine, Kyoto University, 54 Syogoin-kawaharacho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Naotaka Sunada
- Department of Neuropsychiatry, Kansai Medical University, 10-15 Fumizono-cho, Moriguchi-shi, Osaka, 570-8506, Japan
| | - Hirotsugu Kawashima
- Department of Psychiatry, Toyooka Hospital, 1094, Tobera, Toyooka-shi, Hyogo, 668-8501, Japan
| | - Chiara Fabbri
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Viale Carlo Pepoli 5, 40123, Bologna, Italy
| | - Masaki Kato
- Department of Neuropsychiatry, Kansai Medical University, 10-15 Fumizono-cho, Moriguchi-shi, Osaka, 570-8506, Japan
| | - Aran Tajika
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Toshihiko Kinoshita
- Department of Neuropsychiatry, Kansai Medical University, 10-15 Fumizono-cho, Moriguchi-shi, Osaka, 570-8506, Japan
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Viale Carlo Pepoli 5, 40123, Bologna, Italy
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Shaefi S, Mittel AM, Hyam JA, Boone MD, Chen CC, Kasper EM. Hypothermia for severe traumatic brain injury in adults: Recent lessons from randomized controlled trials. Surg Neurol Int 2016; 7:103. [PMID: 28168089 PMCID: PMC5223395 DOI: 10.4103/2152-7806.194816] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/26/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a worldwide health concern associated with significant morbidity and mortality. In the United States, severe TBI is managed according to recommendations set forth in 2007 by the Brain Trauma Foundation (BTF), which were based on relatively low quality clinical trials. These guidelines prescribed the use of hypothermia for the management of TBI. Several randomized controlled trials (RCTs) of hypothermia for TBI have since been conducted. Despite this new literature, there is ongoing controversy surrounding the use of hypothermia for the management of severe TBI. METHODS We searched the PubMed database for all RCTs of hypothermia for TBI since 2007 with the intent to review the methodology outcomes of these trials. Furthermore, we aimed to develop evidence-based, expert opinions based on these recent studies. RESULTS We identified 8 RCTs of therapeutic hypothermia published since 2007 that focused on changes in neurologic outcomes or mortality in patients with severe TBI. The majority of these trials did not identify improvement with the use of hypothermia, though there were subgroups of patients that may have benefited from hypothermia. Differences in methodology prevented direct comparison between studies. CONCLUSIONS A growing body of literature disfavors the use of hypothermia for the management of severe TBI. In general, empiric hypothermia for severe TBI should be avoided. However, based on the results of recent trials, there may be some patients, such as those in Asian centers or with focal neurologic injury, who may benefit from hypothermia.
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Affiliation(s)
- Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Aaron M. Mittel
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jonathan A. Hyam
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - M. Dustin Boone
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Clark C. Chen
- Division of Neurosurgery, University of California, San Diego, California, USA
| | - Ekkehard M. Kasper
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Cinotti R, Piriou N, Launey Y, Le Tourneau T, Lamer M, Delater A, Trochu JN, Brisard L, Lakhal K, Bourcier R, Desal H, Seguin P, Mallédant Y, Blanloeil Y, Feuillet F, Asehnoune K, Rozec B. Speckle tracking analysis allows sensitive detection of stress cardiomyopathy in severe aneurysmal subarachnoid hemorrhage patients. Intensive Care Med 2016; 42:173-82. [PMID: 26499884 DOI: 10.1007/s00134-015-4106-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 05/04/2015] [Indexed: 01/01/2023]
Abstract
PURPOSE Stress cardiomyopathy is a common life-threatening complication after aneurysmal subarachnoid hemorrhage (SAH). We hypothesized that left ventricular (LV) longitudinal strain alterations assessed with speckle tracking could identify early systolic function impairment. METHODS This was an observational single-center prospective pilot controlled study conducted in a neuro-intensive care unit. Forty-six patients with severe SAH with a World Federation of Neurological Surgeons grade (WFNS) ≥ III were included. Transthoracic echocardiography (TTE) was performed on day 1, day 3, and day 7 after the patient's admission. A cardiologist blinded to the patient's management analyzed the LV global longitudinal strain (GLS). The control group comprised normal subjects matched according to gender and age. RESULTS On day 1 median (25th-75th percentile) GLS was clearly impaired in SAH patients compared to controls [-16.7 (-18.7/-13.7) % versus -20 (-22/-19) %, p < 0.0001], whereas LVEF was preserved [65 (59-70) %]. GLS was severely impaired in patients with a WFNS score of V versus III-IV [-15.6 (-16.9/-12.3) % versus -17.8 (-20.6/-15.8) %, p = 0.008]. Seventeen (37 %) patients had a severe GLS alteration (>- 16 %). In these patients, GLS improved from day 1 [-12.4 (-14.8/-10.9) %] to last evaluation [-16.2 (-19/-14.6) %, p = 0.0007] in agreement with the natural evolution of stress cardiomyopathy. CONCLUSIONS On the basis of LV GLS assessment, we demonstrated for the first time that myocardial alteration compatible with a stress cardiomyopathy is detectable in up to 37 % of patients with severe SAH while LVEF is preserved. GLS could be used for sensitive detection of stress cardiomyopathy. This is critical because cardiac impairment remains a major cause of morbidity and mortality after SAH.
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41
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Huang HW, Zhang GB, Zhou JX. Would decompressive craniectomy really bring the hope to severe traumatic brain injury? J Thorac Dis 2016; 8:E1505-E1507. [PMID: 28066644 DOI: 10.21037/jtd.2016.11.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Hua-Wei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing100050, China
| | - Guo-Bin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100050, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing100050, China
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42
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Hirst TC, Watzlawick R, Rhodes JK, Macleod MR, Andrews PJD. Study protocol - A systematic review and meta-analysis of hypothermia in experimental traumatic brain injury: Why have promising animal studies not been replicated in pragmatic clinical trials? ACTA ACUST UNITED AC 2016; 3:e00020. [PMID: 27867522 PMCID: PMC5101852 DOI: 10.1002/ebm2.20] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 08/23/2016] [Indexed: 01/29/2023]
Abstract
Traumatic brain injury (TBI) is a major cause of death and permanent disability. Systemic hypothermia, a treatment used in TBI for many decades, has recently been found to be associated with neutral or unfavourable clinical outcomes despite apparently promising preclinical research. Systematic review and meta‐analysis is a tool to summarize literature and observe trends in experimental design and quality that underpin its general conclusions. Here we aim to use these techniques to describe the use of hypothermia in animal TBI models, collating data relating to outcome and both study design and quality. From here we intend to observe correlations between features and attempt to explain any discrepancies found between animal and clinical data. This protocol describes the relevant methodology in detail.
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Affiliation(s)
- Theodore C Hirst
- Centre for Clinical Brain Sciences University of Edinburgh Edinburgh UK; Department of Neurosurgery Royal Victoria Hospital Belfast UK
| | - Ralf Watzlawick
- Department of Neurology and Experimental Neurology Charité Campus Mitte, Charité-Universitätsmedizin Berlin Germany
| | - Jonathan K Rhodes
- Department of Critical Care, Anaesthesia & Pain Medicine University of Edinburgh Edinburgh UK
| | - Malcolm R Macleod
- Centre for Clinical Brain Sciences University of Edinburgh Edinburgh UK
| | - Peter J D Andrews
- Department of Critical Care, Anaesthesia & Pain Medicine University of Edinburgh Edinburgh UK
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43
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Agrawal S, Branco RG. Neuroprotective measures in children with traumatic brain injury. World J Crit Care Med 2016; 5:36-46. [PMID: 26855892 PMCID: PMC4733454 DOI: 10.5492/wjccm.v5.i1.36] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/01/2015] [Accepted: 01/11/2016] [Indexed: 02/06/2023] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability in children. Severe TBI is a leading cause of death and often leads to life changing disabilities in survivors. The modern management of severe TBI in children on intensive care unit focuses on preventing secondary brain injury to improve outcome. Standard neuroprotective measures are based on management of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) to optimize the cerebral blood flow and oxygenation, with the intention to avoid and minimise secondary brain injury. In this article, we review the current trends in management of severe TBI in children, detailing the general and specific measures followed to achieve the desired ICP and CPP goals. We discuss the often limited evidence for these therapeutic interventions in children, extrapolation of data from adults, and current recommendation from paediatric guidelines. We also review the recent advances in understanding the intracranial physiology and neuroprotective therapies, the current research focus on advanced and multi-modal neuromonitoring, and potential new therapeutic and prognostic targets.
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44
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Andresen M, Gazmuri JT, Marín A, Regueira T, Rovegno M. Therapeutic hypothermia for acute brain injuries. Scand J Trauma Resusc Emerg Med 2015; 23:42. [PMID: 26043908 PMCID: PMC4456795 DOI: 10.1186/s13049-015-0121-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 04/29/2015] [Indexed: 02/07/2023] Open
Abstract
Therapeutic hypothermia, recently termed target temperature management (TTM), is the cornerstone of neuroprotective strategy. Dating to the pioneer works of Fay, nearly 75 years of basic and clinical evidence support its therapeutic value. Although hypothermia decreases the metabolic rate to restore the supply and demand of O₂, it has other tissue-specific effects, such as decreasing excitotoxicity, limiting inflammation, preventing ATP depletion, reducing free radical production and also intracellular calcium overload to avoid apoptosis. Currently, mild hypothermia (33°C) has become a standard in post-resuscitative care and perinatal asphyxia. However, evidence indicates that hypothermia could be useful in neurologic injuries, such as stroke, subarachnoid hemorrhage and traumatic brain injury. In this review, we discuss the basic and clinical evidence supporting the use of TTM in critical care for acute brain injury that extends beyond care after cardiac arrest, such as for ischemic and hemorrhagic strokes, subarachnoid hemorrhage, and traumatic brain injury. We review the historical perspectives of TTM, provide an overview of the techniques and protocols and the pathophysiologic consequences of hypothermia. In addition, we include our experience of managing patients with acute brain injuries treated using endovascular hypothermia.
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Affiliation(s)
- Max Andresen
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
| | - Jose Tomás Gazmuri
- Hospital de Urgencia Asistencia Pública, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Arnaldo Marín
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
| | - Tomas Regueira
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
| | - Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
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45
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Abstract
OPINION STATEMENT Pediatric severe traumatic brain injury continues to be a major cause of disability and death. Rapid initial airway and hemodynamic stabilization is critical, followed by the need for immediate recognition of intracranial pathology that requires neurosurgical intervention. Intracranial hypertension and cerebral hypoperfusion have been recognized as major insults after trauma and management should be directed at preventing both. Sedation with opioids, moderate hyperventilation to arterial carbon dioxide level of 35-40 mmHg, hyperosmolar therapy with 3 % saline or mannitol, normothermia, and cerebrospinal fluid drainage continue to be the cornerstones of initial management of intracranial hypertension (intracranial pressure >20 mmHg). Refractory intracranial hypertension is treated with high-dose barbiturate therapy to achieve medical burst suppression on electroencephalography and decompressive craniectomy. In addition, those children require antiepileptic medications for seizure prophylaxis, adequate nutritional management, and early physical therapy and rehabilitation referrals. Most of the evidence for care of children with brain injury comes from center-specific practice and experience rather than objective data. This lack of evidence provides the ground for ongoing research; nevertheless, outcomes after traumatic brain injury continue to show improvement.
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Affiliation(s)
- Haifa Mtaweh
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada,
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46
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Oshorov AV, Popugaev KA, Savin IA, Gavrilov AG, Kravchuk AD, Potapov AA. [Prх-monitoring based decision-making about decompressive craniectomy in a patient with severe traumatic brain injury. A case report]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2015; 79:92-99. [PMID: 26977799 DOI: 10.17116/neiro201579692-99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The presented case illustrates a new approach to making a decision about decompressive craniectomy in the patient with sever traumatic brain injury and intracranial hypertension. The approach is based on continuous assessment of cerebral autoregulation using Prx-monitoring in addition to monitoring of intracranial pressure and cerebral perfusion pressure. Prx-monitoring enables timely detection of autoregulation failure and provides the opportunity to make a decision about decompressive craniectomy before starting such aggressive methods of intensive care as hypothermia or barbiturate coma.
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Affiliation(s)
- A V Oshorov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - K A Popugaev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I A Savin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A G Gavrilov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A D Kravchuk
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A A Potapov
- Burdenko Neurosurgical Institute, Moscow, Russia
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47
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Popugaev KA, Savin IA, Oshorov AV, Kurdumova NV, Ershova ON, Lubnin AU, Kadashev BA, Kalinin PL, Kutin MA, Killeen T, Cesnulis E, Melieste R. Postsurgical meningitis complicated by severe refractory intracranial hypertension with limited treatment options: the role of mild therapeutic hypothermia. J Neurol Surg Rep 2014; 75:e224-9. [PMID: 25485219 PMCID: PMC4242895 DOI: 10.1055/s-0034-1387188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/03/2014] [Indexed: 12/19/2022] Open
Abstract
Intracranial hypertension is a commonly encountered neurocritical care problem. If first-tier therapy is ineffective, second-tier therapy must be initiated. In many cases, the full arsenal of established treatment options is available. However, situations occasionally arise in which only a narrow range of options is available to neurointensivists. We present a rare clinical scenario in which therapeutic hypothermia was the only available method for controlling intracranial pressure and that demonstrates the efficacy and safety of the Thermogard (Zoll, Chelmsford, Massachusetts, United States) cooling system in creating and maintaining a prolonged hypothermic state. The lifesaving effect of hypothermia was overshadowed by the unfavorable neurologic outcome observed (minimally conscious state on intensive care unit discharge). These results add further evidence to support the role of therapeutic hypothermia in managing intracranial pressure and provide motivation for finding new strategies in combination with hypothermia to improve neurologic outcomes.
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Affiliation(s)
- Konstantin A. Popugaev
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Ivan A. Savin
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Andrew V. Oshorov
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Natalia V. Kurdumova
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Olga N. Ershova
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Andrew U. Lubnin
- Department of Neuroanesthesia, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Boris A. Kadashev
- 8th Neurosurgical Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Pavel L. Kalinin
- 8th Neurosurgical Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Maxim A. Kutin
- 8th Neurosurgical Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Tim Killeen
- Department of Neurosurgery, Klinik Hirslanden, Zürich, Switzerland
| | - Evaldas Cesnulis
- Department of Neurosurgery, Klinik Hirslanden, Zürich, Switzerland
| | - Ronald Melieste
- Temperature Management Division Europe, Zoll Medical Corporation, Chelmsford, Massachusetts, United States
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48
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Jeon SB, Koh Y, Choi HA, Lee K. Critical care for patients with massive ischemic stroke. J Stroke 2014; 16:146-60. [PMID: 25328873 PMCID: PMC4200590 DOI: 10.5853/jos.2014.16.3.146] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 01/29/2023] Open
Abstract
Malignant cerebral edema following ischemic stroke is life threatening, as it can cause inadequate blood flow and perfusion leading to irreversible tissue hypoxia and metabolic crisis. Increased intracranial pressure and brain shift can cause herniation syndrome and finally brain death. Multiple randomized clinical trials have shown that preemptive decompressive hemicraniectomy effectively reduces mortality and morbidity in patients with malignant middle cerebral artery infarction. Another life-saving decompressive surgery is suboccipital craniectomy for patients with brainstem compression by edematous cerebellar infarction. In addition to decompressive surgery, cerebrospinal fluid drainage by ventriculostomy should be considered for patients with acute hydrocephalus following stroke. Medical treatment begins with sedation, analgesia, and general measures including ventilatory support, head elevation, maintaining a neutral neck position, and avoiding conditions associated with intracranial hypertension. Optimization of cerebral perfusion pressure and reduction of intracranial pressure should always be pursued simultaneously. Osmotherapy with mannitol is the standard treatment for intracranial hypertension, but hypertonic saline is also an effective alternative. Therapeutic hypothermia may also be considered for treatment of brain edema and intracranial hypertension, but its neuroprotective effects have not been demonstrated in stroke. Barbiturate coma therapy has been used to reduce metabolic demand, but has become less popular because of its systemic adverse effects. Furthermore, general medical care is critical because of the complex interactions between the brain and other organ systems. Some challenging aspects of critical care, including ventilator support, sedation and analgesia, and performing neurological examinations in the setting of a minimal stimulation protocol, are addressed in this review.
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Affiliation(s)
- Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - H Alex Choi
- Departments of Neurology and Neurosurgery, The University of Texas Medical School at Houston, Houston, Texas, USA
| | - Kiwon Lee
- Departments of Neurology and Neurosurgery, The University of Texas Medical School at Houston, Houston, Texas, USA
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49
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Cinotti R, Ichai C, Orban JC, Kalfon P, Feuillet F, Roquilly A, Riou B, Blanloeil Y, Asehnoune K, Rozec B. Effects of tight computerized glucose control on neurological outcome in severely brain injured patients: a multicenter sub-group analysis of the randomized-controlled open-label CGAO-REA study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:498. [PMID: 25189764 PMCID: PMC4174656 DOI: 10.1186/s13054-014-0498-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 08/18/2014] [Indexed: 01/04/2023]
Abstract
Introduction Hyperglycemia is a marker of poor prognosis in severe brain injuries. There is currently little data regarding the effects of intensive insulin therapy (IIT) on neurological recovery. Methods A sub-group analysis of the randomized-controlled CGAO-REA study (NCT01002482) in surgical intensive care units (ICU) of two university hospitals. Patients with severe brain injury, with an expected ICU length of stay ≥48 hours were included. Patients were randomized between a conventional glucose management group (blood glucose target between 5.5 and 9 mmol.L−1) and an IIT group (blood glucose target between 4.4 and 6 mmol.L−1). The primary outcome was the day-90 neurological outcome evaluated with the Glasgow outcome scale. Results A total of 188 patients were included in this analysis. In total 98 (52%) patients were randomized in the control group and 90 (48%) in the IIT group. The mean Glasgow coma score at baseline was 7 (±4). Patients in the IIT group received more insulin (130 (68 to 251) IU versus 74 (13 to 165) IU in the control group, P = 0.01), had a significantly lower morning blood glucose level (5.9 (5.1 to 6.7) mmol.L−1 versus 6.5 (5.6 to 7.2) mmol.L−1, P <0.001) in the first 5 days after ICU admission. The IIT group experienced more episodes of hypoglycemia (P <0.0001). In the IIT group 24 (26.6%) patients had a favorable neurological outcome (good recovery or moderate disability) compared to 31 (31.6%) in the control group (P = 0.4). There were no differences in day-28 mortality. The occurrence of hypoglycemia did not influence the outcome. Conclusions In this sub-group analysis of a large multicenter randomized trial, IIT did not appear to alter the day-90 neurological outcome or ICU morbidity in severe brain injured patients or ICU morbidity.
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50
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De Vis JB, Hendrikse J, Petersen ET, de Vries LS, van Bel F, Alderliesten T, Negro S, Groenendaal F, Benders MJNL. Arterial spin-labelling perfusion MRI and outcome in neonates with hypoxic-ischemic encephalopathy. Eur Radiol 2014. [PMID: 25097129 DOI: 10.1007/s00330‐014‐3352‐1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE Hyperperfusion may be related to outcome in neonates with hypoxic-ischemic encephalopathy (HIE). The purpose of this study was to evaluate whether arterial spin labelling (ASL) perfusion is associated with outcome in neonates with HIE and to compare the predictive value of ASL MRI to known MRI predictive markers. METHODS Twenty-eight neonates diagnosed with HIE and assessed with MR imaging (conventional MRI, diffusion-weighted MRI, MR spectroscopy [MRS], and ASL MRI) were included. Perfusion in the basal ganglia and thalami was measured. Outcome at 9 or 18 months of age was scored as either adverse (death or cerebral palsy) or favourable. RESULTS The median (range) perfusion in the basal ganglia and thalami (BGT) was 63 (28-108) ml/100 g/min in the neonates with adverse outcome and 28 (12-51) ml/100 g/min in the infants with favourable outcome (p < 0.01). The area-under-the-curve was 0.92 for ASL MRI, 0.97 for MRI score, 0.96 for Lac/NAA and 0.92 for ADC in the BGT. The combination of Lac/NAA and ASL MRI results was the best predictor of outcome (r(2) = 0.86, p < 0.001). CONCLUSION Higher ASL perfusion values in neonates with HIE are associated with a worse neurodevelopmental outcome. A combination of the MRS and ASL MRI information is the best predictor of outcome. KEY POINTS • Arterial spin labelling MRI can predict outcome in neonates with hypoxic-ischemic encephalopathy • Basal ganglia and thalami perfusion is higher in neonates with adverse outcome • Arterial spin labelling complements known MRI parameters in the prediction of outcome • The combined information of ASL and MRS measurements is the best predictor of outcome.
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Affiliation(s)
- Jill B De Vis
- Department of Radiology, University Medical Center Utrecht, HP E 01.132, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands,
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