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Huang SS, Huang CH, Hsu NT, Ong HN, Lin JJ, Wu YW, Chen WT, Chen WJ, Chang WT, Tsai MS. Application of Phosphorylated Tau for Predicting Outcomes Among Sudden Cardiac Arrest Survivors. Neurocrit Care 2024:10.1007/s12028-024-02055-6. [PMID: 38982004 DOI: 10.1007/s12028-024-02055-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/21/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Phosphorylated Tau (p-Tau), an early biomarker of neuronal damage, has emerged as a promising candidate for predicting neurological outcomes in cardiac arrest (CA) survivors. Despite its potential, the correlation of p-Tau with other clinical indicators remains underexplored. This study assesses the predictive capability of p-Tau and its effectiveness when used in conjunction with other predictors. METHODS In this single-center retrospective study, 230 CA survivors had plasma and brain computed tomography scans collected within 24 h after the return of spontaneous circulation (ROSC) from January 2016 to June 2023. The patients with prearrest Cerebral Performance Category scores ≥ 3 were excluded (n = 33). The neurological outcomes at discharge with Cerebral Performance Category scores 1-2 indicated favorable outcomes. Plasma p-Tau levels were measured using an enzyme-linked immunosorbent assay, diastolic blood pressure (DBP) was recorded after ROSC, and the gray-to-white matter ratio (GWR) was calculated from brain computed tomography scans within 24 h after ROSC. RESULTS Of 197 patients enrolled in the study, 54 (27.4%) had favorable outcomes. Regression analysis showed that higher p-Tau levels correlated with unfavorable neurological outcomes. The levels of p-Tau were significantly correlated with DBP and GWR. For p-Tau to differentiate between neurological outcomes, an optimal cutoff of 456 pg/mL yielded an area under the receiver operating characteristic curve of 0.71. Combining p-Tau, GWR, and DBP improved predictive accuracy (area under the receiver operating characteristic curve = 0.80 vs. 0.71, p = 0.008). CONCLUSIONS Plasma p-Tau levels measured within 24 h following ROSC, particularly when combined with GWR and DBP, may serve as a promising biomarker of neurological outcomes in CA survivors, with higher levels predicting unfavorable outcomes.
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Affiliation(s)
- Sih-Shiang Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | | | - Hooi-Nee Ong
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Jr-Jiun Lin
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | | | - Wei-Ting Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- Cardiology Division, Department of Internal Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- Department of Internal Medicine, Min-Shen General Hospital, Taoyuan, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
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Ahmad SA, Kapoor S, Muquit S, Gusdon A, Khanduja S, Ziai W, Everett AD, Whitman G, Cho SM, On Behalf Of Herald Investigators. Brain injury plasma biomarkers in patients on veno-arterial extracorporeal membrane oxygenation: A pilot prospective observational study. Perfusion 2024:2676591241256006. [PMID: 38757156 DOI: 10.1177/02676591241256006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Early diagnosis of acute brain injury (ABI) is critical for patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) to guide anticoagulation strategy; however, neurological assessment in ECMO is often limited by patient sedation. METHODS In this pilot study of adults from June 2018 to May 2019, plasma samples of glial fibrillary acidic protein (GFAP), neurofilament light chain (NFL), and tubulin associated unit (Tau) were collected daily after V-A ECMO cannulation and measured using a multiplex platform. Primary outcomes were occurrence of ABI, assessed clinically, and neurologic outcome, assessed by modified Rankin Scale (mRS). RESULTS Of 20 consented patients (median age = 48.5°years; 55% female), 8 (40%) had ABI and 15 (75%) had unfavorable neurologic outcome at discharge. 10 (50%) patients were centrally cannulated. Median duration on ECMO was 4.5°days (IQR: 2.5-9.5). Peak GFAP, NFL, and Tau levels were higher in patients with ABI vs. without (AUC = 0.77; 0.85; 0.57, respectively) and in patients with unfavorable vs. favorable neurologic outcomes (AUC = 0.64; 0.59; 0.73, respectively). GFAP elevated first, NFL elevated to the highest degree, and Tau showed limited change regardless of ABI. CONCLUSION Further studies are warranted to determine how plasma biomarkers may facilitate early detection of ABIs in V-A ECMO to assist timely clinical decision-making.
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Affiliation(s)
- Syed Ameen Ahmad
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shrey Kapoor
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Siam Muquit
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron Gusdon
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Shivalika Khanduja
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy Ziai
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allen D Everett
- Department of Pediatrics, Blalock-Taussig-Thomas Congenital Heart Center, Johns Hopkins University, Baltimore, MD, USA
| | - Glenn Whitman
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Arctaedius I, Levin H, Thorgeirsdóttir B, Moseby-Knappe M, Cronberg T, Annborn M, Nielsen N, Zetterberg H, Blennow K, Ashton NJ, Frigyesi A, Friberg H, Lybeck A, Mattsson-Carlgren N. Plasma glial fibrillary acidic protein and tau: predictors of neurological outcome after cardiac arrest. Crit Care 2024; 28:116. [PMID: 38594704 PMCID: PMC11003115 DOI: 10.1186/s13054-024-04889-0] [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: 12/30/2023] [Accepted: 03/23/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND The purpose was to evaluate glial fibrillary acidic protein (GFAP) and total-tau in plasma as predictors of poor neurological outcome after out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA), including comparisons with neurofilament light (NFL) and neuron-specific enolase (NSE). METHODS Retrospective multicentre observational study of patients admitted to an intensive care unit (ICU) in three hospitals in Sweden 2014-2018. Blood samples were collected at ICU admission, 12 h, and 48 h post-cardiac arrest. Poor neurological outcome was defined as Cerebral Performance Category 3-5 at 2-6 months after cardiac arrest. Plasma samples were retrospectively analysed for GFAP, tau, and NFL. Serum NSE was analysed in clinical care. Prognostic performances were tested with the area under the receiver operating characteristics curve (AUC). RESULTS Of the 428 included patients, 328 were OHCA, and 100 were IHCA. At ICU admission, 12 h and 48 h post-cardiac arrest, GFAP predicted neurological outcome after OHCA with AUC (95% CI) 0.76 (0.70-0.82), 0.86 (0.81-0.90) and 0.91 (0.87-0.96), and after IHCA with AUC (95% CI) 0.77 (0.66-0.87), 0.83 (0.74-0.92) and 0.83 (0.71-0.95). At the same time points, tau predicted outcome after OHCA with AUC (95% CI) 0.72 (0.66-0.79), 0.75 (0.69-0.81), and 0.93 (0.89-0.96) and after IHCA with AUC (95% CI) 0.61 (0.49-0.74), 0.68 (0.56-0.79), and 0.77 (0.65-0.90). Adding the change in biomarker levels between time points did not improve predictive accuracy compared to the last time point. In a subset of patients, GFAP at 12 h and 48 h, as well as tau at 48 h, offered similar predictive value as NSE at 48 h (the earliest time point NSE is recommended in guidelines) after both OHCA and IHCA. The predictive performance of NFL was similar or superior to GFAP and tau at all time points after OHCA and IHCA. CONCLUSION GFAP and tau are promising biomarkers for neuroprognostication, with the highest predictive performance at 48 h after OHCA, but not superior to NFL. The predictive ability of GFAP may be sufficiently high for clinical use at 12 h after cardiac arrest.
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Affiliation(s)
- Isabelle Arctaedius
- Department of Clinical Sciences, Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden.
| | - Helena Levin
- Department of Research and Education, Skane University Hospital and Department of Clinical Sciences, Anaesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Bergthóra Thorgeirsdóttir
- Department of Clinical Sciences, Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Malmö, Sweden
| | - Marion Moseby-Knappe
- Neurology and Rehabilitation Medicine, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Skane University Hospital, Lund University, Lund, Sweden
| | - Martin Annborn
- Department of Clinical Sciences, Anaesthesia and Intensive Care, Helsingborg Hospital, Lund University, Helsingborg, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences, Anaesthesia and Intensive Care, Helsingborg Hospital, Lund University, Helsingborg, Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
- Wisconsin Alzheimer's Disease Research Centre, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Nicholas J Ashton
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- NIHR Biomedical Research Centre for Mental Health and Biomedical Research Unit for Dementia at South London and Maudsley NHS Foundation, London, UK
- Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Attila Frigyesi
- Department of Clinical Sciences, Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Malmö, Sweden
| | - Anna Lybeck
- Department of Clinical Sciences, Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Niklas Mattsson-Carlgren
- Department of Clinical Sciences, Neurology, Skane University Hospital, Lund University, Lund, Sweden
- Clinical Memory Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden
- Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden
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Arctaedius I, Levin H, Larsson M, Friberg H, Cronberg T, Nielsen N, Moseby-Knappe M, Lybeck A. 2021 European Resuscitation Council/European Society of Intensive Care Medicine Algorithm for Prognostication of Poor Neurological Outcome After Cardiac Arrest-Can Entry Criteria Be Broadened? Crit Care Med 2024; 52:531-541. [PMID: 38059722 DOI: 10.1097/ccm.0000000000006113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES To explore broadened entry criteria of the 2021 European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM) algorithm for neuroprognostication including patients with ongoing sedation and Glasgow Coma Scale-Motor score (GCS-M) scores 4-5. DESIGN Retrospective multicenter observational study. SETTING Four ICUs, Skane, Sweden. PATIENTS Postcardiac arrest patients managed at targeted temperature 36°C, 2014-2018. Neurologic outcome was assessed after 2-6 months according to the Cerebral Performance Category scale. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In 794 included patients, median age was 69.5 years (interquartile range, 60.6-77.0 yr), 241 (30.4%) were female, 550 (69.3%) had an out-of-hospital cardiac arrest, and 314 (41.3%) had a shockable rhythm. Four hundred ninety-five patients were dead at follow-up, 330 of 495 died after a decision on withdrawal of life-sustaining therapies. At 72 hours after cardiac arrest 218 patients remained unconscious. The entry criteria of the original algorithm (GCS-M 1-3) was fulfilled by 163 patients and 115 patients with poor outcome were identified, with false positive rate (FPR) of 0% (95% CI, 0-79.4%) and sensitivity of 71.0% (95% CI, 63.6-77.4%). Inclusion of patients with ongoing sedation identified another 13 patients with poor outcome, generating FPR of 0% (95% CI, 0-65.8%) and sensitivity of 69.6% (95% CI, 62.6-75.8%). Inclusion of all unconscious patients (GCS-M 1-5), regardless of sedation, identified one additional patient, generating FPR of 0% (95% CI, 0-22.8) and sensitivity of 62.9% (95% CI, 56.1-69.2). The few patients with true negative prediction (patients with good outcome not fulfilling guideline criteria of a poor outcome) generated wide 95% CI for FPR. CONCLUSION The 2021 ERC/ESICM algorithm for neuroprognostication predicted poor neurologic outcome with a FPR of 0%. Broadening inclusion criteria to include all unconscious patients regardless of ongoing sedation identified an additional small number of patients with poor outcome but did not affect the FPR. Results are limited by high rate of withdrawal of life-sustaining therapies and few patients with true negative prediction.
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Affiliation(s)
- Isabelle Arctaedius
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Helena Levin
- Anaesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University and Department of Research & Education, Skane University Hospital, Lund, Sweden
| | - Melker Larsson
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Malmö, Sweden
| | - Tobias Cronberg
- Neurology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Marion Moseby-Knappe
- Neurology and Rehabilitation Medicine, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Anna Lybeck
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
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5
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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Pluta R, Czuczwar SJ. Ischemia-Reperfusion Programming of Alzheimer's Disease-Related Genes-A New Perspective on Brain Neurodegeneration after Cardiac Arrest. Int J Mol Sci 2024; 25:1291. [PMID: 38279289 PMCID: PMC10816023 DOI: 10.3390/ijms25021291] [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: 12/29/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 01/28/2024] Open
Abstract
The article presents the latest data on pathological changes after cerebral ischemia caused by cardiac arrest. The data include amyloid accumulation, tau protein modification, neurodegenerative and cognitive changes, and gene and protein changes associated with Alzheimer's disease. We present the latest data on the dysregulation of genes related to the metabolism of the amyloid protein precursor, tau protein, autophagy, mitophagy, apoptosis, and amyloid and tau protein transport genes. We report that neuronal death after cerebral ischemia due to cardiac arrest may be dependent and independent of caspase. Moreover, neuronal death dependent on amyloid and modified tau protein has been demonstrated. Finally, the results clearly indicate that changes in the expression of the presented genes play an important role in acute and secondary brain damage and the development of post-ischemic brain neurodegeneration with the Alzheimer's disease phenotype. The data indicate that the above genes may be a potential therapeutic target for brain therapy after ischemia due to cardiac arrest. Overall, the studies show that the genes studied represent attractive targets for the development of new therapies to minimize ischemic brain injury and neurological dysfunction. Additionally, amyloid-related genes expression and tau protein gene modification after cerebral ischemia due to cardiac arrest are useful in identifying ischemic mechanisms associated with Alzheimer's disease. Cardiac arrest illustrates the progressive, time- and area-specific development of neuropathology in the brain with the expression of genes responsible for the processing of amyloid protein precursor and the occurrence of tau protein and symptoms of dementia such as those occurring in patients with Alzheimer's disease. By carefully examining the common genetic processes involved in these two diseases, these data may help unravel phenomena associated with the development of Alzheimer's disease and neurodegeneration after cerebral ischemia and may lead future research on Alzheimer's disease or cerebral ischemia in new directions.
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Affiliation(s)
- Ryszard Pluta
- Department of Pathophysiology, Medical University of Lublin, 20-090 Lublin, Poland;
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7
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Soulier T, Colliot O, Ayache N, Rohaut B. How will tomorrow's algorithms fuse multimodal data? The example of the neuroprognosis in Intensive Care. Anaesth Crit Care Pain Med 2023; 42:101301. [PMID: 37709200 DOI: 10.1016/j.accpm.2023.101301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 09/03/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Théodore Soulier
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inserm, AP-HP, Hôpital de la Pitié Salpêtrière, F-75013, Paris, France.
| | - Olivier Colliot
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inria, Inserm, AP-HP, Hôpital de la Pitié Salpêtrière, F-75013, Paris, France
| | | | - Benjamin Rohaut
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inserm, AP-HP, Hôpital de la Pitié Salpêtrière, F-75013, Paris, France; Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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8
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Kapoor S, Kolchinski A, Gusdon AM, Premraj L, Cho SM. Plasma biomarkers for brain injury in extracorporeal membrane oxygenation. Acute Crit Care 2023; 38:389-398. [PMID: 38052506 DOI: 10.4266/acc.2023.01368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 11/24/2023] [Indexed: 12/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with refractory cardiorespiratory failure. Despite its benefits, ECMO carries a significant risk of neurological complications, including acute brain injury (ABI). Although standardized neuromonitoring and neurological care have been shown to improve early detection of ABI, the inability to perform neuroimaging in a timely manner is a major limitation in the accurate diagnosis of neurological complications. Therefore, blood-based biomarkers capable of detecting ongoing brain injury at the bedside are of great clinical significance. This review aims to provide a concise review of the current literature on plasma biomarkers for ABI in patients on ECMO support.
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Affiliation(s)
- Shrey Kapoor
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anna Kolchinski
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron M Gusdon
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Lavienraj Premraj
- Griffith University School of Medicine, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia
| | - Sung-Min Cho
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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9
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Nguyen AM, Saini V, Hinson HE. Blood-Based Biomarkers for Neuroprognostication in Acute Brain Injury. Semin Neurol 2023; 43:689-698. [PMID: 37751855 PMCID: PMC10668565 DOI: 10.1055/s-0043-1775764] [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] [Indexed: 09/28/2023]
Abstract
Acute brain injury causes loss of functionality in patients that often is devastating. Predicting the degree of functional loss and overall prognosis requires a multifaceted approach to help patients, and more so their families, make important decisions regarding plans and goals of care. A variety of blood-based markers have been studied as one aspect of this determination. In this review, we discuss CNS-derived and systemic markers that have been studied for neuroprognostication purposes. We discuss the foundation of each protein, the conditions in which it has been studied, and how the literature has used these markers for interpretation. We also discuss challenges to using each marker in each section as well.
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Affiliation(s)
- Andrew M. Nguyen
- Neurosciences Critical Care Program, Department of Neurology, Oregon Health & Science University, Portland, Oregon
| | - Vishal Saini
- Neurosciences Critical Care Program, Department of Neurology, Oregon Health & Science University, Portland, Oregon
| | - H. E. Hinson
- Department of Neurology, University of California San Francisco, San Francisco, California
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10
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Kondziella D. Neuroprognostication after cardiac arrest: what the cardiologist should know. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:550-558. [PMID: 36866627 DOI: 10.1093/ehjacc/zuad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/04/2023]
Abstract
Two aspects are a key to mastering prognostication of comatose cardiac arrest survivors: a detailed knowledge about the clinical trajectories of consciousness recovery (or lack thereof) and the ability to correctly interpret the results of multimodal investigations, which include clinical examination, electroencephalography, neuroimaging, evoked potentials, and blood biomarkers. While the very good and the very poor ends of the clinical spectrum typically do not pose diagnostic challenges, the intermediate 'grey zone' of post-cardiac arrest encephalopathy requires cautious interpretation of the available information and sufficiently long clinical observation. Late recovery of coma patients with initially ambiguous diagnostic results is increasingly reported, as are unresponsive patients with various forms of residual consciousness, including so-called cognitive motor dissociation, rendering prognostication of post-anoxic coma highly complex. The aim of this paper is to provide busy clinicians with a high-yield, concise overview of neuroprognostication after cardiac arrest, emphasizing notable developments in the field since 2020.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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11
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Zhang X, Zheng X, Dai Z, Zheng H. The development and validation of a nomogram to determine neurological outcomes in cardiac arrest patients. BMC Anesthesiol 2023; 23:289. [PMID: 37620773 PMCID: PMC10463846 DOI: 10.1186/s12871-023-02251-5] [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: 03/06/2023] [Accepted: 08/19/2023] [Indexed: 08/26/2023] Open
Abstract
OBJECTIVES This study aimed to investigate the variables that influence neurological functional restoration in cardiac arrest patients and construct a nomogram to predict neurofunctional prognosis. PATIENTS AND METHODS We extracted the data from the Dryad database. Associations between patient variables and neurological outcomes were examined by logistic regression models. On the basis of these predictors, a prognostic nomogram was constructed. The identification and calibration of the prognostic nomogram were evaluated through the receiver operating characteristic (ROC) curve, the calibration curve, and the concordance index (C-index). RESULTS A total of 374 cardiac arrest individuals were recruited in the research. Sixty percent of the participants had an adverse neurological result. The multivariable logistic regression analysis for poor neurological recovery, which showed patient age ≥ 65 years, previous neurological disease, witnessed arrest, bystander cardio-pulmonary resuscitation(CPR), cardiac arrest presenting with a non-shockable rhythm, total epinephrine dose ≥ 2.5 mg at the time of resuscitation and acute kidney injury(AKI) remained independent predictors for neurological outcomes. CONCLUSIONS The novel nomogram based on clinical characteristics is an efficient tool to predict neurological outcomes in cardiac arrest patients, which may help clinicians identifying high-risk patients and tailoring personalized treatment regimens.
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Affiliation(s)
- Xuru Zhang
- Department of Anesthesiology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou City, 350014, China, No 420 Fuma Road, Jinan District, Fujian Province
| | - Xiaowei Zheng
- Department of Otorhinolaryngology Head and Neck Surgery, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China
| | - Zhisen Dai
- Department of Anesthesiology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou City, 350014, China, No 420 Fuma Road, Jinan District, Fujian Province
| | - Huizhe Zheng
- Department of Anesthesiology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou City, 350014, China, No 420 Fuma Road, Jinan District, Fujian Province.
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12
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Sumner BD, Hahn CW. Prognosis of Cardiac Arrest-Peri-arrest and Post-arrest Considerations. Emerg Med Clin North Am 2023; 41:601-616. [PMID: 37391253 DOI: 10.1016/j.emc.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
There has been only a small improvement in survival and neurologic outcomes in patients with cardiac arrest in recent decades. Type of arrest, length of total arrest time, and location of arrest alter the trajectory of survival and neurologic outcome. In the post-arrest phase, clinical markers such as blood markers, pupillary light response, corneal reflex, myoclonic jerking, somatosensory evoked potential, and electroencephalography testing can be used to help guide neurological prognostication. Most of the testing should be performed 72 hours post-arrest with special considerations for longer observation periods in patients who underwent TTM or who had prolonged sedation and/or neuromuscular blockade.
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Affiliation(s)
- Brian D Sumner
- Institute for Critical Care Medicine, 1468 Madison Avenue, Guggenheim Pavilion 6 East Room 378, New York, NY 10029, USA.
| | - Christopher W Hahn
- Department of Emergency Medicine, Mount Sinai Morningside-West, 1000 10th Avenue, New York, NY 10019, USA
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13
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Lileikyte G, Bakochi A, Ali A, Moseby-Knappe M, Cronberg T, Friberg H, Lilja G, Levin H, Årman F, Kjellström S, Dankiewicz J, Hassager C, Malmström J, Nielsen N. Serum proteome profiles in patients treated with targeted temperature management after out-of-hospital cardiac arrest. Intensive Care Med Exp 2023; 11:43. [PMID: 37455296 DOI: 10.1186/s40635-023-00528-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/03/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Definition of temporal serum proteome profiles after out-of-hospital cardiac arrest may identify biological processes associated with severe hypoxia-ischaemia and reperfusion. It may further explore intervention effects for new mechanistic insights, identify candidate prognostic protein biomarkers and potential therapeutic targets. This pilot study aimed to investigate serum proteome profiles from unconscious patients admitted to hospital after out-of-hospital cardiac arrest according to temperature treatment and neurological outcome. METHODS Serum samples at 24, 48, and 72 h after cardiac arrest at three centres included in the Target Temperature Management after out-of-hospital cardiac arrest trial underwent data-independent acquisition mass spectrometry analysis (DIA-MS) to find changes in serum protein concentrations associated with neurological outcome at 6-month follow-up and targeted temperature management (TTM) at 33 °C as compared to 36 °C. Neurological outcome was defined according to Cerebral Performance Category (CPC) scale as "good" (CPC 1-2, good cerebral performance or moderate disability) or "poor" (CPC 3-5, severe disability, unresponsive wakefulness syndrome, or death). RESULTS Of 78 included patients [mean age 66 ± 12 years, 62 (80.0%) male], 37 (47.4%) were randomised to TTM at 36 °C. Six-month outcome was poor in 47 (60.3%) patients. The DIA-MS analysis identified and quantified 403 unique human proteins. Differential protein abundance testing comparing poor to good outcome showed 19 elevated proteins in patients with poor outcome (log2-fold change (FC) range 0.28-1.17) and 16 reduced proteins (log2(FC) between - 0.22 and - 0.68), involved in inflammatory/immune responses and apoptotic signalling pathways for poor outcome and proteolysis for good outcome. Analysis according to level of TTM showed a significant protein abundance difference for six proteins [five elevated proteins in TTM 36 °C (log2(FC) between 0.33 and 0.88), one reduced protein (log2(FC) - 0.6)] mainly involved in inflammatory/immune responses only at 48 h after cardiac arrest. CONCLUSIONS Serum proteome profiling revealed an increase in inflammatory/immune responses and apoptosis in patients with poor outcome. In patients with good outcome, an increase in proteolysis was observed, whereas TTM-level only had a modest effect on the proteome profiles. Further validation of the differentially abundant proteins in response to neurological outcome is necessary to validate novel biomarker candidates that may predict prognosis after cardiac arrest.
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Affiliation(s)
- Gabriele Lileikyte
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Helsingborg Hospital, Svartbrödragränden 3, 251 87, Helsingborg, Sweden.
| | - Anahita Bakochi
- Swedish National Infrastructure for Biological Mass Spectrometry (BioMS), Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Infection Medicine, Lund University, Lund, Sweden
| | - Ashfaq Ali
- National Bioinformatics Infrastructure Sweden (NBIS), SciLifeLab, Department of Immunotechnology, Lund University, Lund, Sweden
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Helena Levin
- Department of Clinical Sciences Lund, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | - Filip Årman
- Swedish National Infrastructure for Biological Mass Spectrometry (BioMS), Lund University, Lund, Sweden
| | - Sven Kjellström
- Swedish National Infrastructure for Biological Mass Spectrometry (BioMS), Lund University, Lund, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Johan Malmström
- Department of Clinical Sciences Lund, Infection Medicine, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Helsingborg Hospital, Svartbrödragränden 3, 251 87, Helsingborg, Sweden
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14
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Song H, Bang HJ, You Y, Park JS, Kang C, Kim HJ, Park KN, Oh SH, Youn CS. Novel serum biomarkers for predicting neurological outcomes in postcardiac arrest patients treated with targeted temperature management. Crit Care 2023; 27:113. [PMID: 36927495 PMCID: PMC10022069 DOI: 10.1186/s13054-023-04400-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVE To determine the clinical feasibility of novel serum biomarkers in out-of-hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM). METHODS This study was a prospective observational study conducted on OHCA patients who underwent TTM. We measured conventional biomarkers, neuron‑specific enolase and S100 calcium-binding protein (S-100B), as well as novel biomarkers, including tau protein, neurofilament light chain (NFL), glial fibrillary acidic protein (GFAP), and ubiquitin C-terminal hydrolase-L1 (UCH-L1), at 0, 24, 48, and 72 h after the return of spontaneous circulation identified by SIMOA immunoassay. The primary outcome was poor neurological outcome at 6 months after OHCA. RESULTS A total of 100 patients were included in this study from August 2018 to May 2020. Among the included patients, 46 patients had good neurologic outcomes at 6 months after OHCA. All conventional and novel serum biomarkers had the ability to discriminate between the good and poor neurological outcome groups (p < 0.001). The area under the curves of the novel serum biomarkers were highest at 72 h after cardiac arrest (CA) (0.906 for Tau, 0.946 for NFL, 0.875 for GFAP, and 0.935 for UCH-L1). The NFL at 72 h after CA had the highest sensitivity (77.1%, 95% CI 59.9-89.6) in predicting poor neurological outcomes while maintaining 100% specificity. CONCLUSION Novel serum biomarkers reliably predicted poor neurological outcomes for patients with OHCA treated with TTM when life-sustaining therapy was not withdrawn. Cutoffs from two large existing studies (TTM and COMACARE substudy) were externally validated in our study. The predictive power of the novel biomarkers was the highest at 72 h after CA.
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Affiliation(s)
- Hwan Song
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Hyo Jin Bang
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea.
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15
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Leithner C. Can early blood biomarkers guide brain imaging strategy after cardiac arrest? Resuscitation 2023; 184:109710. [PMID: 36717053 DOI: 10.1016/j.resuscitation.2023.109710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 02/01/2023]
Affiliation(s)
- Christoph Leithner
- Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität zu Berlin, Department of Neurology, Augustenburger Platz 1, 13353 Berlin, Germany.
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16
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Brain injury markers in blood predict signs of hypoxic ischaemic encephalopathy on head computed tomography after cardiac arrest. Resuscitation 2023; 184:109668. [PMID: 36563954 DOI: 10.1016/j.resuscitation.2022.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND/AIM Signs of hypoxic ischaemic encephalopathy (HIE) on head computed tomography (CT) predicts poor neurological outcome after cardiac arrest. We explore whether levels of brain injury markers in blood could predict the likelihood of HIE on CT. METHODS Retrospective analysis of CT performed at 24-168 h post cardiac arrest on clinical indication within the Target Temperature Management after out-of-hospital cardiac arrest-trial. Biomarkers prospectively collected at 24- and 48 h post-arrest were analysed for neuron specific enolase (NSE), neurofilament light (NFL), total-tau and glial fibrillary acidic protein (GFAP). HIE was assessed through visual evaluation and quantitative grey-white-matter ratio (GWR) was retrospectively calculated on Swedish subjects with original images available. RESULTS In total, 95 patients were included. The performance to predict HIE on CT (performed at IQR 73-116 h) at 48 h was similar for all biomarkers, assessed as area under the receiving operating characteristic curve (AUC) NSE 0.82 (0.71-0.94), NFL 0.79 (0.67-0.91), total-tau 0.84 (0.74-0.95), GFAP 0.79 (0.67-0.90). The predictive performance of biomarker levels at 24 h was AUC 0.72-0.81. At 48 h biomarker levels below Youden Index accurately excluded HIE in 77.3-91.7% (negative predictive value) and levels above Youden Index correctly predicted HIE in 73.3-83.7% (positive predictive value). NSE cut-off at 48 h was 48 ng/ml. Elevated biomarker levels irrespective of timepoint significantly correlated with lower GWR. CONCLUSION Biomarker levels can assess the likelihood of a patient presenting with HIE on CT and could be used to select suitable patients for CT-examination during neurological prognostication in unconscious cardiac arrest patients.
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17
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Fagerli E, Escobar I, Ferrier FJ, Jackson CW, Perez-Lao EJ, Perez-Pinzon MA. Sirtuins and cognition: implications for learning and memory in neurological disorders. Front Physiol 2022; 13:908689. [PMID: 35936890 PMCID: PMC9355297 DOI: 10.3389/fphys.2022.908689] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022] Open
Abstract
Sirtuins are an evolutionarily conserved family of regulatory proteins that function in an NAD+ -dependent manner. The mammalian family of sirtuins is composed of seven histone deacetylase and ADP-ribosyltransferase proteins (SIRT1-SIRT7) that are found throughout the different cellular compartments of the cell. Sirtuins in the brain have received considerable attention in cognition due to their role in a plethora of metabolic and age-related diseases and their ability to induce neuroprotection. More recently, sirtuins have been shown to play a role in normal physiological cognitive function, and aberrant sirtuin function is seen in pathological cellular states. Sirtuins are believed to play a role in cognition through enhancing synaptic plasticity, influencing epigenetic regulation, and playing key roles in molecular pathways involved with oxidative stress affecting mitochondrial function. This review aims to discuss recent advances in the understanding of the role of mammalian sirtuins in cognitive function and the therapeutic potential of targeting sirtuins to ameliorate cognitive deficits in neurological disorders.
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Affiliation(s)
| | | | | | | | | | - Miguel A. Perez-Pinzon
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States
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18
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Lima MN, Barbosa-Silva MC, Maron-Gutierrez T. Microglial Priming in Infections and Its Risk to Neurodegenerative Diseases. Front Cell Neurosci 2022; 16:878987. [PMID: 35783096 PMCID: PMC9240317 DOI: 10.3389/fncel.2022.878987] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/26/2022] [Indexed: 11/29/2022] Open
Abstract
Infectious diseases of different etiologies have been associated with acute and long-term neurological consequences. The primary cause of these consequences appears to be an inflammatory process characterized primarily by a pro-inflammatory microglial state. Microglial cells, the local effectors’ cells of innate immunity, once faced by a stimulus, alter their morphology, and become a primary source of inflammatory cytokines that increase the inflammatory process of the brain. This inflammatory scenario exerts a critical role in the pathogenesis of neurodegenerative diseases. In recent years, several studies have shown the involvement of the microglial inflammatory response caused by infections in the development of neurodegenerative diseases. This has been associated with a transitory microglial state subsequent to an inflammatory response, known as microglial priming, in which these cells are more responsive to stimuli. Thus, systemic inflammation and infections induce a transitory state in microglia that may lead to changes in their state and function, making priming them for subsequent immune challenges. However, considering that microglia are long-lived cells and are repeatedly exposed to infections during a lifetime, microglial priming may not be beneficial. In this review, we discuss the relationship between infections and neurodegenerative diseases and how this may rely on microglial priming.
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Affiliation(s)
- Maiara N. Lima
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Rio de Janeiro, Brazil
| | - Maria C. Barbosa-Silva
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Rio de Janeiro, Brazil
| | - Tatiana Maron-Gutierrez
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Rio de Janeiro, Brazil
- National Institute of Science and Technology on Neuroimmunomodulation, Rio de Janeiro, Brazil
- *Correspondence: Tatiana Maron-Gutierrez;
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19
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Moseby-Knappe M, Levin H, Blennow K, Ullén S, Zetterberg H, Lilja G, Dankiewicz J, Jakobsen JC, Lagebrant A, Friberg H, Nichol A, Ainschough K, Eastwood GM, Wise MP, Thomas M, Keeble T, Cariou A, Leithner C, Rylander C, Düring J, Bělohlávek J, Grejs A, Borgquist O, Undén J, Simon M, Rolny V, Piehler A, Cronberg T, Nielsen N. Biomarkers of brain injury after cardiac arrest; a statistical analysis plan from the TTM2 trial biobank investigators. Resusc Plus 2022; 10:100258. [PMID: 35677835 PMCID: PMC9168690 DOI: 10.1016/j.resplu.2022.100258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/23/2022] [Accepted: 05/23/2022] [Indexed: 01/27/2023] Open
Abstract
Background Several biochemical markers in blood correlate with the magnitude of brain injury and may be used to predict neurological outcome after cardiac arrest. We present a protocol for the evaluation of prognostic accuracy of brain injury markers after cardiac arrest. The aim is to define the best predictive marker and to establish clinically useful cut-off levels for routine implementation. Methods Prospective international multicenter trial within the Targeted Hypothermia versus Targeted Normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial in collaboration with Roche Diagnostics International AG. Samples were collected 0, 24, 48, and 72 hours after randomisation (serum) and 0 and 48 hours after randomisation (plasma), and pre-analytically processed at each site before storage in a central biobank. Routine markers neuron-specific enolase (NSE) and S100B, and neurofilament light, total-tau and glial fibrillary acidic protein will be batch analysed using novel Elecsys® electrochemiluminescence immunoassays on a Cobas e601 instrument. Results Statistical analysis will be reported according to the Standards for Reporting Diagnostic accuracy studies (STARD) and will include comparisons for prediction of good versus poor functional outcome at six months post-arrest, by modified Rankin Scale (0-3 vs. 4-6), using logistic regression models and receiver operating characteristics curves, evaluation of mortality at six months according to biomarker levels and establishment of cut-off values for prediction of poor neurological outcome at 95-100% specificities. Conclusions This prospective trial may establish a standard methodology and clinically appropriate cut-off levels for the optimal biomarker of brain injury which predicts poor neurological outcome after cardiac arrest.
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Affiliation(s)
- Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Helena Levin
- Department of Clinical Sciences Lund, Anaesthesiology and Intensive Care, Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience & Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Susann Ullén
- Clinical Studies Sweden - Forum South, Skåne University Hospital, Lund, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience & Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom
- UK Dementia Research Institute at UCL, London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Janus Christian Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark
| | - Alice Lagebrant
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Alistair Nichol
- University College Dublin, Clinical Research Centre, St Vincent's University Hospital Dublin, Ireland
- The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne. Australia
- Intensive Care Unit, Alfred Hospital, Melbourne, Australia
| | - Kate Ainschough
- University College Dublin, Clinical Research Centre, St Vincent's University Hospital Dublin, Ireland
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom
| | - Matthew Thomas
- Intensive Care Unit, University Hospitals, Bristol and Weston, England, United Kingdom
| | - Thomas Keeble
- Essex Cardiothoracic Centre, MSE, Basildon, Essex, United Kingdom
- MTRC, Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom
| | - Alain Cariou
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris, France, Paris Cité University, Paris, France
| | - Christoph Leithner
- AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Rylander
- Anaesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Joachim Düring
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Jan Bělohlávek
- Second Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Anders Grejs
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ola Borgquist
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Johan Undén
- Department of Clinical Sciences Malmö, Dept. Operation and Intensive Care, Lund University, Hallands Hospital Halmstad, Halmstad, Sweden
| | - Maryline Simon
- Clinical Development Department, Roche Diagnostics International AG, Rotkreuz, Switzerland
| | - Vinzent Rolny
- Biostatistical Department, Roche Diagnostics International AG, Rotkreuz, Switzerland
| | - Alex Piehler
- Biostatistical Department, Roche Diagnostics International AG, Rotkreuz, Switzerland
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Helsingborg Hospital, Lund, Sweden
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20
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Humaloja J, Ashton NJ, Skrifvars MB. Brain Injury Biomarkers for Predicting Outcome After Cardiac Arrest. Crit Care 2022; 26:81. [PMID: 35337359 DOI: 10.1186/s13054-022-03913-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Jaana Humaloja
- Department of Emergency Care and Services, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicholas J Ashton
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
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21
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You Y, Kang C, Jeong W, Park JS, Cho Y, Ahn HJ, Min JH, In YN. The Early Prognostic Value and Optimal Time of Measuring Serum and Cerebrospinal Fluid Tau Protein for Neurologic Outcomes in Postcardiac Arrest Patients Treated with Targeted Temperature Management. Ther Hypothermia Temp Manag 2022; 12:191-199. [PMID: 35290743 DOI: 10.1089/ther.2021.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Neuroprognostication of cardiac arrest patients remains a challenge. We evaluated the early prognostic value and optimal time of measuring serum and cerebrospinal fluid (CSF) tau protein levels to predict neurologic outcome in postcardiac arrest patients treated with targeted temperature management (TTM). We also evaluated the cutoff values in predicting poor outcomes. Patients treated with TTM following cardiac arrest, from May 2018 to June 2019, were included in the study. Serum and CSF tau levels were obtained and compared immediately, at 24, 48, and 72 hours after return of spontaneous circulation (ROSC). The area under the receiver-operating characteristic curve (AUROC) and the Delong method were used to identify the cutoff values of serum and CSF tau protein levels in predicting poor outcomes at each interval. Of 38 patients enrolled, 16 experienced poor outcomes. Both serum and CSF tau levels were consistently higher in the poor outcome group than in the good outcome group. The AUROCs of serum and CSF tau protein were not significantly different at each time point. Immediately after ROSC, sensitivities of both serum and CSF tau protein levels were 31.25% at 100% specificity and increased to 86.6% and 73.3%, respectively, at 72 hours. This study demonstrates that serum and CSF tau protein levels could be used as valuable predictors of neurologic outcomes in postcardiac arrest patients treated with TTM. The early optimal time for measuring the serum and CSF tau protein levels was determined to be 72 hours after ROSC.
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Affiliation(s)
- Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Yongchul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea.,Department of Emergency Medicine, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea.,Department of Emergency Medicine, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
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22
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Rosén A, Gennser M, Oscarsson N, Kvarnström A, Sandström G, Seeman-Lodding H, Simrén J, Zetterberg H. Protein tau concentration in blood increases after SCUBA diving: an observational study. Eur J Appl Physiol 2022; 122:993-1005. [PMID: 35142945 PMCID: PMC8926952 DOI: 10.1007/s00421-022-04892-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/05/2022] [Indexed: 11/27/2022]
Abstract
Purpose It is speculated that diving might be harmful to the nervous system. The aim of this study was to determine if established markers of neuronal injury were increased in the blood after diving. Methods Thirty-two divers performed two identical dives, 48 h apart, in a water-filled hyperbaric chamber pressurized to an equivalent of 42 m of sea water for 10 min. After one of the two dives, normobaric oxygen was breathed for 30 min, with air breathed after the other. Blood samples were obtained before and at 30–45 and 120 min after diving. Concentrations of glial fibrillary acidic, neurofilament light, and tau proteins were measured using single molecule array technology. Doppler ultrasound was used to detect venous gas emboli. Results Tau was significantly increased at 30–45 min after the second dive (p < 0.0098) and at 120 min after both dives (p < 0.0008/p < 0.0041). Comparison of matching samples showed that oxygen breathing after diving did not influence tau results. There was no correlation between tau concentrations and the presence of venous gas emboli. Glial fibrillary acidic protein was decreased 30–45 min after the first dive but at no other point. Neurofilament light concentrations did not change. Conclusions Tau seems to be a promising marker of dive-related neuronal stress, which is independent of the presence of venous gas emboli. Future studies could validate these results and determine if there is a quantitative relationship between dive exposure and change in tau blood concentration. Supplementary Information The online version contains supplementary material available at 10.1007/s00421-022-04892-9.
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Affiliation(s)
- Anders Rosén
- Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
- Department of Anaesthesia and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Mikael Gennser
- Swedish Aerospace Physiology Centre, Division of Environmental Physiology, Department of Biomedical Engineering and Health Systems, School of Engineering Sciences in Chemistry, Biotechnology and Health, Royal Institute of Technology, KTH, Stockholm, Sweden
| | - Nicklas Oscarsson
- Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Anaesthesia and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Andreas Kvarnström
- Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Anaesthesia and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Sandström
- Department of Anaesthesia and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Swedish Armed Forces, Center for Defence Medicine, Gothenburg, Sweden
| | - Helen Seeman-Lodding
- Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Anaesthesia and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joel Simrén
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Department of Neurodegenerative Disease, Institute of Neurology, University College London, London, UK
- UK Dementia Research Institute, University College London, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
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23
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GFAp and tau protein as predictors of neurological outcome after out-of-hospital cardiac arrest: A post hoc analysis of the COMACARE trial. Resuscitation 2021; 170:141-149. [PMID: 34863908 PMCID: PMC8786666 DOI: 10.1016/j.resuscitation.2021.11.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/15/2022]
Abstract
Aim To determine the ability of serum glial fibrillary acidic protein (GFAp) and tau protein to predict neurological outcome after out-of-hospital cardiac arrest (OHCA). Methods We measured plasma concentrations of GFAp and tau of patients included in the previously published COMACARE trial (NCT02698917) on intensive care unit admission and at 24, 48, and 72 h after OHCA, and compared them to neuron specific enolase (NSE). NSE concentrations were determined already during the original trial. We defined unfavourable outcome as a cerebral performance category (CPC) score of 3–5 six months after OHCA. We determined the prognostic accuracy of GFAp and tau using the receiver operating characteristic curve and area under the curve (AUROC). Results Overall, 39/112 (35%) patients had unfavourable outcomes. Over time, both markers were evidently higher in the unfavourable outcome group (p < 0.001). At 48 h, the median (interquartile range) GFAp concentration was 1514 (886–4995) in the unfavourable versus 238 (135–463) pg/ml in the favourable outcome group (p < 0.001). The corresponding tau concentrations were 99.6 (14.5–352) and 3.0 (2.2–4.8) pg/ml (p < 0.001). AUROCs at 48 and 72 h were 0.91 (95% confidence interval 0.85–0.97) and 0.91 (0.85–0.96) for GFAp and 0.93 (0.86–0.99) and 0.95 (0.89–1.00) for tau. Corresponding AUROCs for NSE were 0.86 (0.79–0.94) and 0.90 (0.82–0.97). The difference between the prognostic accuracies of GFAp or tau and NSE were not statistically significant. Conclusions At 48 and 72 h, serum both GFAp and tau demonstrated excellent accuracy in predicting outcomes after OHCA but were not superior to NSE. Clinical trial registration NCT02698917 (https://www.clinicaltrials.gov/ct2/show/NCT02698917).
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24
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Alcolea D, Delaby C, Muñoz L, Torres S, Estellés T, Zhu N, Barroeta I, Carmona-Iragui M, Illán-Gala I, Santos-Santos MÁ, Altuna M, Sala I, Sánchez-Saudinós MB, Videla L, Valldeneu S, Subirana A, Pegueroles J, Hirtz C, Vialaret J, Lehmann S, Karikari TK, Ashton NJ, Blennow K, Zetterberg H, Belbin O, Blesa R, Clarimón J, Fortea J, Lleó A. Use of plasma biomarkers for AT(N) classification of neurodegenerative dementias. J Neurol Neurosurg Psychiatry 2021; 92:1206-1214. [PMID: 34103344 DOI: 10.1136/jnnp-2021-326603] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/22/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES All categories included in the AT(N) classification can now be measured in plasma. However, their agreement with cerebrospinal fluid (CSF) markers is not fully established. A blood signature to generate the AT(N) classification would facilitate early diagnosis of patients with Alzheimer's disease (AD) through an easy and minimally invasive approach. METHODS We measured Aβ, pTau181 and neurofilament light (NfL) in 150 plasma samples of the Sant Pau Initiative on Neurodegeneration cohort including patients with mild cognitive impairment, AD dementia, frontotemporal dementia, dementia with Lewy bodies and cognitively normal participants. We classified participants in the AT(N) categories according to CSF biomarkers and studied the diagnostic value of plasma biomarkers within each category individually and in combination. RESULTS The plasma Aβ composite, pTau181 and NfL yielded areas under the curve (AUC) of 0.75, 0.78 and 0.88 to discriminate positive and negative participants in their respective A, T and N categories. The combination of all three markers did not outperform pTau181 alone (AUC=0.81) to discriminate A+T+ from A-T- participants. There was a moderate correlation between plasma Aβ composite and CSF Aβ1-42/Aβ1-40 (Rho=-0.5, p<0.001) and between plasma pTau181 and CSF pTau181 in the entire cohort (Rho=0.51, p<0.001). NfL levels in plasma showed high correlation with those in CSF (Rho=0.78, p<0.001). CONCLUSIONS Plasma biomarkers are useful to detect the AT(N) categories, and their use can differentiate patients with pathophysiological evidence of AD. A blood AT(N) signature may facilitate early diagnosis and follow-up of patients with AD through an easy and minimally invasive approach.
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Affiliation(s)
- Daniel Alcolea
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain .,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Constance Delaby
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,IRMB, INM, Université de Montpellier, INSERM, CHU de Montpellier, Laboratoire de Biochimie-Protéomique clinique, Montpellier, France
| | - Laia Muñoz
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Soraya Torres
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Teresa Estellés
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Nuole Zhu
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Isabel Barroeta
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - María Carmona-Iragui
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Ignacio Illán-Gala
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Miguel Ángel Santos-Santos
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Miren Altuna
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Isabel Sala
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Mª Belén Sánchez-Saudinós
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Laura Videla
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain.,Fundación Catalana Síndrome Down, Barcelona, Catalunya, Spain
| | - Sílvia Valldeneu
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Andrea Subirana
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Jordi Pegueroles
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Christophe Hirtz
- IRMB, INM, Université de Montpellier, INSERM, CHU de Montpellier, Laboratoire de Biochimie-Protéomique clinique, Montpellier, France
| | - Jérôme Vialaret
- IRMB, INM, Université de Montpellier, INSERM, CHU de Montpellier, Laboratoire de Biochimie-Protéomique clinique, Montpellier, France
| | - Sylvain Lehmann
- IRMB, INM, Université de Montpellier, INSERM, CHU de Montpellier, Laboratoire de Biochimie-Protéomique clinique, Montpellier, France
| | - Thomas K Karikari
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg Sahlgrenska Academy, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Nicholas J Ashton
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg Sahlgrenska Academy, Mölndal, Sweden.,Department of Old Age Psychiatry, King's College London Institute of Psychiatry Psychology and Neuroscience, London, UK.,Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden.,NIHR Biomedical Research Centre for Mental Health and Biomedical Research Unit for Dementia, South London and Maudsley NHS Foundation, London, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg Sahlgrenska Academy, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg Sahlgrenska Academy, Mölndal, Sweden.,Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute, UCL, London, UK
| | - Olivia Belbin
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Rafael Blesa
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Jordi Clarimón
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Juan Fortea
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
| | - Alberto Lleó
- Department of Neurology, Institut d'Investigacions Biomèdiques Sant Pau - Hospital de Sant Pau, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, CIBERNED, Madrid, Spain
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25
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Wilcox C, Choi CW, Cho SM. Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The addition of extracorporeal membrane oxygenation (ECMO) to conventional cardiopulmonary resuscitation (CPR), termed extracorporeal cardiopulmonary resuscitation (ECPR), has significantly improved survival in selected patient populations. Despite this advancement, significant neurological impairment persists in approximately half of survivors. ECPR represents a potential advancement for patients who experience refractory cardiac arrest (CA) due to a reversible etiology and do not regain spontaneous circulation. Important risk factors for acute brain injury (ABI) in ECPR include lack of perfusion, reperfusion, and altered cerebral autoregulation. The initial hypoxic-ischemic injury caused by no-flow and low-flow states after CA and during CPR is compounded by reperfusion, hyperoxia during ECMO support, and nonpulsatile blood flow. Additionally, ECPR patients are at risk for Harlequin syndrome with peripheral cannulation, which can lead to preferential perfusion of cerebral vessels with deoxygenated blood. Lastly, the oxygenator membrane is prothrombotic and requires systemic anticoagulation. The two competing phenomena result in thrombus formation, hemolysis, and thrombocytopenia, increasing the risk of ischemic and hemorrhagic ABI. In addition to clinical studies, we assessed available ECPR animal models to identify the mechanisms underlying ABI at the cellular level. Standardized multimodal neurological monitoring may facilitate early detection of and intervention for ABI. With the increasing use of ECPR, it is critical to understand the pathophysiology of ABI, its prevention, and the management strategies for improving the outcomes of ECPR. Translational and clinical research focusing on acute ABI immediately after ECMO cannulation and its short- and long-term neurological outcomes are warranted.
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26
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Chatterjee P, Pedrini S, Ashton NJ, Tegg M, Goozee K, Singh AK, Karikari TK, Simrén J, Vanmechelen E, Armstrong NJ, Hone E, Asih PR, Taddei K, Doré V, Villemagne VL, Sohrabi HR, Zetterberg H, Masters CL, Blennow K, Martins RN. Diagnostic and prognostic plasma biomarkers for preclinical Alzheimer's disease. Alzheimers Dement 2021; 18:1141-1154. [PMID: 34494715 DOI: 10.1002/alz.12447] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/03/2021] [Accepted: 07/16/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION This study involved a parallel comparison of the diagnostic and longitudinal monitoring potential of plasma glial fibrillary acidic protein (GFAP), total tau (t-tau), phosphorylated tau (p-tau181 and p-tau231), and neurofilament light (NFL) in preclinical Alzheimer's disease (AD). METHODS Plasma proteins were measured using Simoa assays in cognitively unimpaired older adults (CU), with either absence (Aβ-) or presence (Aβ+) of brain amyloidosis. RESULTS Plasma GFAP, t-tau, p-tau181, and p-tau231 concentrations were higher in Aβ+ CU compared with Aβ- CU cross-sectionally. GFAP had the highest effect size and area under the curve (AUC) in differentiating between Aβ+ and Aβ- CU; however, no statistically significant differences were observed between the AUCs of GFAP, p-tau181, and p-tau231, but all were significantly higher than the AUC of NFL, and the AUC of GFAP was higher than the AUC of t-tau. The combination of a base model (BM), comprising the AD risk factors, age, sex, and apolipoprotein E gene (APOE) ε4 status with GFAP was observed to have a higher AUC (>90%) compared with the combination of BM with any of the other proteins investigated in the current study. Longitudinal analyses showed increased GFAP and p-tau181 in Aβ+ CU and increased NFL in Aβ- CU, over a 12-month duration. GFAP, p-tau181, p-tau231, and NFL showed significant correlations with cognition, whereas no significant correlations were observed with hippocampal volume. DISCUSSION These findings highlight the diagnostic and longitudinal monitoring potential of GFAP and p-tau for preclinical AD.
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Affiliation(s)
- Pratishtha Chatterjee
- Department of Biomedical Sciences, Macquarie University, North Ryde, New South Wales, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Steve Pedrini
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Nicholas J Ashton
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Department of Old Age Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Michelle Tegg
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Kathryn Goozee
- Department of Biomedical Sciences, Macquarie University, North Ryde, New South Wales, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.,School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley, Western Australia, Australia.,The Cooperative Research Centre for Mental Health, Carlton South, Australia.,KaRa Institute of Neurological Disease, Macquarie Park, Australia
| | - Abhay K Singh
- Macquarie Business School, Macquarie University, North Ryde, New South Wales, Australia
| | - Thomas K Karikari
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Joel Simrén
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Nicola J Armstrong
- Department of Mathematics & Statistics, Curtin University, Bentley, Western Australia, Australia
| | - Eugene Hone
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Prita R Asih
- Department of Nuclear Medicine and Centre for PET, Austin Health, Heidelberg, Victoria, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Kevin Taddei
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.,Australian Alzheimer's Research Foundation, Nedlands, Western Australia, Australia
| | - Vincent Doré
- eHealth, CSIRO Health and Biosecurity, Herston, Queensland, Australia.,Department of Nuclear Medicine and Centre for PET, Austin Health, Heidelberg, Victoria, Australia
| | - Victor L Villemagne
- Department of Nuclear Medicine and Centre for PET, Austin Health, Heidelberg, Victoria, Australia.,Department of Psychiatry, University of Pittsburgh, Pennsylvania, USA
| | - Hamid R Sohrabi
- Department of Biomedical Sciences, Macquarie University, North Ryde, New South Wales, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.,School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley, Western Australia, Australia.,Australian Alzheimer's Research Foundation, Nedlands, Western Australia, Australia.,Centre for Healthy Ageing, Health Future Institute, Murdoch University, Murdoch, Western Australia, Australia
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Colin L Masters
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ralph N Martins
- Department of Biomedical Sciences, Macquarie University, North Ryde, New South Wales, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.,School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley, Western Australia, Australia.,The Cooperative Research Centre for Mental Health, Carlton South, Australia.,KaRa Institute of Neurological Disease, Macquarie Park, Australia.,Australian Alzheimer's Research Foundation, Nedlands, Western Australia, Australia
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27
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McGuigan S, Evered L, Scott DA, Silbert B, Zetterberg H, Blennow K. Comparing the effect of xenon and sevoflurane anesthesia on postoperative neural injury biomarkers: a randomized controlled trial. Med Gas Res 2021; 12:10-17. [PMID: 34472497 PMCID: PMC8447955 DOI: 10.4103/2045-9912.324591] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
General anesthesia and surgery are associated with an increase in neural injury biomarkers. Elevations of these neural injury biomarkers in the perioperative period are associated with postoperative delirium. Xenon has been shown to be protective against a range of neurological insults in animal models. It remains to be seen if xenon anesthesia is neuroprotective in the perioperative setting in humans. Twenty-four participants scheduled for lithotripsy were randomized to receive either xenon or sevoflurane general anesthesia. There was no statistically significant difference in the concentrations of postoperative neural injury biomarkers between the xenon and sevoflurane group. Following the procedure there was a significant increase in the concentration from baseline of all three biomarkers at 1 hour post-induction with a return to baseline at 5 hours. General anesthesia for lithotripsy was associated with a significant increase at 1 hour post-induction in the neural injury biomarkers total tau, neurofilament light and tau phosphorylated at threonine 181, a marker of tau phosphorylation. The protocol was approved by the St. Vincent’s Hospital Melbourne Ethics Committee (approval No. HREC/18/SVHM/221) on July 20, 2018 and was registered with the Australia New Zealand Clinical Trials Registry (registration No. ACTRN12618000916246) on May 31, 2018.
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Affiliation(s)
- Steven McGuigan
- Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital; Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Lisbeth Evered
- Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital; Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital; Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Brendan Silbert
- Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital; Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology; UK Dementia Research Institute at UCL, London, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
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Dutta A, Alirhayim Z, Masmoudi Y, Azizian J, McDonald L, Jogu HR, Qureshi WT, Majeed N. Brain Natriuretic Peptide as a Marker of Adverse Neurological Outcomes Among Survivors of Cardiac Arrest. J Intensive Care Med 2021; 37:803-809. [PMID: 34459680 DOI: 10.1177/08850666211034728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Neurological prognosis after cardiac arrest remains ill-defined. Plasma brain natriuretic peptide (BNP) may relate to poor neurological prognosis in brain-injury patients, though it has not been well studied in survivors of cardiac arrest. METHODS We performed a retrospective review and examined the association of BNP with mortality and neurological outcomes at discharge in a cohort of cardiac arrest survivors enrolled from January 2012 to December 2016 at the Wake Forest Baptist Hospital, in North Carolina. Cerebral performance category (CPC) and modified Rankin scales were calculated from the chart based on neurological evaluation performed at the time of discharge. The cohort was subdivided into quartiles based on their BNP levels after which multivariable adjusted logistic regression models were applied to assess for an association between BNP and poor neurological outcomes as defined by a CPC of 3 to 4 and a modified Rankin scale of 4 to 5. RESULTS Of the 657 patients included in the study, 254 patients survived until discharge. Among these, poor neurological status was observed in 101 (39.8%) patients that had a CPC score of 3 to 4 and 97 patients (38.2%) that had a modified Rankin scale of 4 to 5. Mean BNP levels were higher in patients with poor neurological status compared to those with good neurological status at discharge (P = .03 for CPC 3-4 and P = .02 for modified Rankin score 4-5). BNP levels however, did not vary significantly between patients that survived and those that expired (P = .22). BNP did emerge as a significant discriminator between patients with severe neurological disability at discharge when compared to those without. The area under the curve for BNP predicting a modified Rankin score of 4 to 5 was 0.800 (95% confidence interval [CI] 0.756-0.844, P < .001) and for predicting CPC 3 to 4 was 0.797 (95% CI 0.756-0.838, P < .001). BNP was able to significantly improve the net reclassification index and integrated discriminatory increment (P < .05). BNP was not associated with long-term all-cause mortality (P > .05). CONCLUSIONS In survivors of either inpatient or out-of-hospital cardiac arrest, increased BNP levels measured at the time of arrest predicted severe neurological disability at discharge. We did not observe an independent association between BNP levels and long-term all-cause mortality. BNP may be a useful biomarker for predicting adverse neurological outcomes in survivors of cardiac arrest.
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Affiliation(s)
- Abhishek Dutta
- 571678Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zaid Alirhayim
- 144889King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Youssef Masmoudi
- 12280Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - John Azizian
- 12280Wake Forest University School of Medicine, Winston Salem, NC, USA
| | | | - Hanumantha R Jogu
- 12280Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Waqas T Qureshi
- 12262University of Massachusetts School of Medicine, Worcester, MA, USA
| | - Nasir Majeed
- Wake Forest Baptist Hospital, North Carolina, USA
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29
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Moseby-Knappe M, Mattsson-Carlgren N, Stammet P, Backman S, Blennow K, Dankiewicz J, Friberg H, Hassager C, Horn J, Kjaergaard J, Lilja G, Rylander C, Ullén S, Undén J, Westhall E, Wise MP, Zetterberg H, Nielsen N, Cronberg T. Serum markers of brain injury can predict good neurological outcome after out-of-hospital cardiac arrest. Intensive Care Med 2021; 47:984-994. [PMID: 34417831 PMCID: PMC8421280 DOI: 10.1007/s00134-021-06481-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/13/2021] [Indexed: 12/31/2022]
Abstract
Purpose The majority of unconscious patients after cardiac arrest (CA) do not fulfill guideline criteria for a likely poor outcome, their prognosis is considered “indeterminate”. We compared brain injury markers in blood for prediction of good outcome and for identifying false positive predictions of poor outcome as recommended by guidelines. Methods Retrospective analysis of prospectively collected serum samples at 24, 48 and 72 h post arrest within the Target Temperature Management after out-of-hospital cardiac arrest (TTM)-trial. Clinically available markers neuron-specific enolase (NSE) and S100B, and novel markers neurofilament light chain (NFL), total tau, ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) and glial fibrillary acidic protein (GFAP) were analysed. Normal levels with a priori cutoffs specified by reference laboratories or defined from literature were used to predict good outcome (no to moderate disability, Cerebral Performance Category scale 1–2) at 6 months. Results Seven hundred and seventeen patients were included. Normal NFL, tau and GFAP had the highest sensitivities (97.2–98% of poor outcome patients had abnormal serum levels) and NPV (normal levels predicted good outcome in 87–95% of patients). Normal S100B and NSE predicted good outcome with NPV 76–82.2%. Normal NSE correctly identified 67/190 (35.3%) patients with good outcome among those classified as “indeterminate outcome” by guidelines. Five patients with single pathological prognostic findings despite normal biomarkers had good outcome. Conclusion Low levels of brain injury markers in blood are associated with good neurological outcome after CA. Incorporating biomarkers into neuroprognostication may help prevent premature withdrawal of life-sustaining therapy. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06481-4.
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Affiliation(s)
- Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden.
| | - Niklas Mattsson-Carlgren
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden.,Clinical Memory Research Unit, Faculty of Medicine, Lund University, Lund, Sweden.,Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden
| | - Pascal Stammet
- Medical and Health Department, National Fire and Rescue Corps, Luxembourg, Luxembourg
| | - Sofia Backman
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janneke Horn
- Department of Intensive Care, Amsterdam Neuroscience, Amsterdam UMC, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Susann Ullén
- Clinical Studies Sweden-Forum South, Skane University Hospital, Lund, Sweden
| | - Johan Undén
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Operation and Intensive Care, Lund University, Hallands Hospital Halmstad, Halland, Sweden
| | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK.,Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
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Abstract
PURPOSE OF REVIEW Recovery after severe brain injury is variable and challenging to accurately predict at the individual patient level. This review highlights new developments in clinical prognostication with a special focus on the prediction of consciousness and increasing reliance on methods from data science. RECENT FINDINGS Recent research has leveraged serum biomarkers, quantitative electroencephalography, MRI, and physiological time-series to build models for recovery prediction. The analysis of high-resolution data and the integration of features from different modalities can be approached with efficient computational techniques. SUMMARY Advances in neurophysiology and neuroimaging, in combination with computational methods, represent a novel paradigm for prediction of consciousness and functional recovery after severe brain injury. Research is needed to produce reliable, patient-level predictions that could meaningfully impact clinical decision making.
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31
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Treatment and Prognosis After Hypoxic-Ischemic Injury. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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32
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Ashton NJ, Suárez‐Calvet M, Karikari TK, Lantero‐Rodriguez J, Snellman A, Sauer M, Simrén J, Minguillon C, Fauria K, Blennow K, Zetterberg H. Effects of pre-analytical procedures on blood biomarkers for Alzheimer's pathophysiology, glial activation, and neurodegeneration. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2021; 13:e12168. [PMID: 34124336 PMCID: PMC8171159 DOI: 10.1002/dad2.12168] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/09/2021] [Accepted: 02/15/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION We tested how tube types (ethylenediaminetetraacetic acid [EDTA], serum, lithium heparin [LiHep], and citrate) and freeze-thaw cycles affect levels of blood biomarkers for Alzheimer's disease (AD) pathophysiology, glial activation, and neuronal injury. METHODS Amyloid beta (Aβ)42, Aβ40, phosphorylated tau181 (p-tau181), glial fibrillary acidic protein, total tau (t-tau), neurofilament light, and phosphorylated neurofilament heavy protein were measured using single molecule arrays. RESULTS LiHep demonstrated the highest mean value for all biomarkers. Tube types were highly correlated for most biomarkers (r > 0.95) but gave significantly different absolute concentrations. Weaker correlations between tube types were found for Aβ42/40 (r = 0.63-0.86) and serum t-tau (r = 0.46-0.64). Freeze-thaw cycles highly influenced levels of serum Aβ and t-tau (P < .0001), and minor decreases in EDTA Aβ40 and EDTA p-tau181 were found after freeze-thaw cycle 4 (P < .05). DISCUSSION The same tube type should be used in research studies on blood biomarkers. Individual concentration cut-offs are needed for each tube type in all tested biomarkers despite being highly correlated. Serum should be avoided for Aβ42, Aβ40, and t-tau. Freeze-thaw cycles > 3 should be avoided for p-tau181.
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Affiliation(s)
- Nicholas J. Ashton
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and PhysiologyThe Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Wallenberg Centre for Molecular and Translational MedicineDepartment of Psychiatry and NeurochemistryInstitute of Neuroscience and Physiologythe Sahlgrenska Academy at the University of GothenburgGothenburgSweden
- Department of Old Age PsychiatryPsychology & NeuroscienceKing's College LondonInstitute of PsychiatryLondonUK
- NIHR Biomedical Research Centre for Mental Health & Biomedical Research Unit for Dementia at South London & Maudsley NHS FoundationLondonUK
| | - Marc Suárez‐Calvet
- Pasqual Maragall FoundationBarcelonaβeta Brain Research Center (BBRC)BarcelonaSpain
- IMIM (Hospital del Mar Medical Research Institute)BarcelonaSpain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES)MadridSpain
- Servei de NeurologiaHospital del MarBarcelonaSpain
| | - Thomas K. Karikari
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and PhysiologyThe Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Juan Lantero‐Rodriguez
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and PhysiologyThe Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Anniina Snellman
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and PhysiologyThe Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Turku PET CentreUniversity of TurkuTurkuFinland
| | - Mathias Sauer
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
| | - Joel Simrén
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and PhysiologyThe Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
| | - Carolina Minguillon
- Pasqual Maragall FoundationBarcelonaβeta Brain Research Center (BBRC)BarcelonaSpain
- IMIM (Hospital del Mar Medical Research Institute)BarcelonaSpain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES)MadridSpain
| | - Karine Fauria
- Pasqual Maragall FoundationBarcelonaβeta Brain Research Center (BBRC)BarcelonaSpain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES)MadridSpain
| | - Kaj Blennow
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and PhysiologyThe Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
| | - Henrik Zetterberg
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and PhysiologyThe Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
- Department of Neurodegenerative DiseaseUCL Institute of NeurologyLondonUK
- UK Dementia Research Institute at UCLLondonUK
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33
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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34
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Kim YM, Jeung KW, Kim WY, Park YS, Oh JS, You YH, Lee DH, Chae MK, Jeong YJ, Kim MC, Ha EJ, Hwang KJ, Kim WS, Lee JM, Cha KC, Chung SP, Park JD, Kim HS, Lee MJ, Na SH, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 5. Post-cardiac arrest care. Clin Exp Emerg Med 2021; 8:S41-S64. [PMID: 34034449 PMCID: PMC8171174 DOI: 10.15441/ceem.21.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon Ho You
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Yoo Jin Jeong
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Min Chul Kim
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Eun Jin Ha
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Jin Hwang
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Myung Lee
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - on behalf of the Steering Committee of 2020 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
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35
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Du L, Zheng K, Feng L, Cao Y, Niu Z, Song Z, Liu Z, Liu X, Xiang X, Zhou Q, Xiong H, Chen F, Zhang G, Ma Q. The first national survey on practices of neurological prognostication after cardiac arrest in China, still a lot to do. Int J Clin Pract 2021; 75:e13759. [PMID: 33098255 DOI: 10.1111/ijcp.13759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/04/2020] [Indexed: 02/05/2023] Open
Abstract
AIMS To investigate current awareness and practices of neurological prognostication in comatose cardiac arrest (CA) patients. METHODS An anonymous questionnaire was distributed to 1600 emergency physicians in 75 hospitals which were selected randomly from China between January and July 2018. RESULTS 92.1% respondents fulfilled the survey. The predictive value of brain stem reflex, motor response and myoclonus was confirmed by 63.5%, 44.6% and 31.7% respondents, respectively. Only 30.7% knew that GWR value < 1.1 indicated poor prognosis and only 8.1% know the most commonly used SSEP N20. Status epilepticus, burst suppression and suppression were considered to predict poor outcome by only 35.0%, 27.4% and 20.9% respondents, respectively. Only 46.7% knew NSE and only 24.7% knew S-100. Only a few respondents knew that neurological prognostication should be performed later than 72 hours from CA either in TTM or non-TTM patients. In practice, the most commonly used method was clinical examination (85.4%). Only 67.9% had used brain CT for prognosis and 18.4% for MRI. NSE (39.6%) was a little more widely used than S-100β (18.0%). However, SSEP (4.4%) and EEG (11.4%) were occasionally performed. CONCLUSIONS Neurological prognostication in CA survivors had not been well understood and performed by emergency physicians in China. They were more likely to use clinical examination rather than objective tools, especially SSEP and EEG, which also illustrated that multimodal approach was not well performed in practice.
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Affiliation(s)
- Lanfang Du
- Emergency Department, The Peking University Third Hospital, Beijing, China
| | - Kang Zheng
- Emergency Department, The Peking University Third Hospital, Beijing, China
| | - Lu Feng
- Emergency Department, The Peking University Third Hospital, Beijing, China
| | - Yu Cao
- Emergency Department, West China Hospital, Chengdu City, China
| | - Zhendong Niu
- Emergency Department, West China Hospital, Chengdu City, China
| | - Zhenju Song
- Emergency Department, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhi Liu
- Emergency Department, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xiaowei Liu
- Emergency Department, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xudong Xiang
- Emergency Department, Second Xiangya Hospital, Central South University, Changsha, China
| | - Qidi Zhou
- Emergency Department, Peking University Shenzhen Hospital, Shenzhen City, China
| | - Hui Xiong
- Emergency Department, Peking University First Hospital, Beijing, China
| | - Fengying Chen
- Emergency Department, The Affiliated Hospital of Innor Mongolia Medical University, Huherhaote City, China
| | - Guoqiang Zhang
- Emergency Department, China-Japan Friendship Hospital, Beijing, China
| | - Qingbian Ma
- Emergency Department, The Peking University Third Hospital, Beijing, China
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 417] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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37
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 338] [Impact Index Per Article: 112.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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Edlow BL, Claassen J, Schiff ND, Greer DM. Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies. Nat Rev Neurol 2021; 17:135-156. [PMID: 33318675 PMCID: PMC7734616 DOI: 10.1038/s41582-020-00428-x] [Citation(s) in RCA: 238] [Impact Index Per Article: 79.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 12/16/2022]
Abstract
Substantial progress has been made over the past two decades in detecting, predicting and promoting recovery of consciousness in patients with disorders of consciousness (DoC) caused by severe brain injuries. Advanced neuroimaging and electrophysiological techniques have revealed new insights into the biological mechanisms underlying recovery of consciousness and have enabled the identification of preserved brain networks in patients who seem unresponsive, thus raising hope for more accurate diagnosis and prognosis. Emerging evidence suggests that covert consciousness, or cognitive motor dissociation (CMD), is present in up to 15-20% of patients with DoC and that detection of CMD in the intensive care unit can predict functional recovery at 1 year post injury. Although fundamental questions remain about which patients with DoC have the potential for recovery, novel pharmacological and electrophysiological therapies have shown the potential to reactivate injured neural networks and promote re-emergence of consciousness. In this Review, we focus on mechanisms of recovery from DoC in the acute and subacute-to-chronic stages, and we discuss recent progress in detecting and predicting recovery of consciousness. We also describe the developments in pharmacological and electrophysiological therapies that are creating new opportunities to improve the lives of patients with DoC.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicholas D Schiff
- Feil Family Brain Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA.
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Andersson P, Johnsson J, Björnsson O, Cronberg T, Hassager C, Zetterberg H, Stammet P, Undén J, Kjaergaard J, Friberg H, Blennow K, Lilja G, Wise MP, Dankiewicz J, Nielsen N, Frigyesi A. Predicting neurological outcome after out-of-hospital cardiac arrest with cumulative information; development and internal validation of an artificial neural network algorithm. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:83. [PMID: 33632280 PMCID: PMC7905905 DOI: 10.1186/s13054-021-03505-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/10/2021] [Indexed: 12/16/2022]
Abstract
Background Prognostication of neurological outcome in patients who remain comatose after cardiac arrest resuscitation is complex. Clinical variables, as well as biomarkers of brain injury, cardiac injury, and systemic inflammation, all yield some prognostic value. We hypothesised that cumulative information obtained during the first three days of intensive care could produce a reliable model for predicting neurological outcome following out-of-hospital cardiac arrest (OHCA) using artificial neural network (ANN) with and without biomarkers. Methods We performed a post hoc analysis of 932 patients from the Target Temperature Management trial. We focused on comatose patients at 24, 48, and 72 h post-cardiac arrest and excluded patients who were awake or deceased at these time points. 80% of the patients were allocated for model development (training set) and 20% for internal validation (test set). To investigate the prognostic potential of different levels of biomarkers (clinically available and research-grade), patients’ background information, and intensive care observation and treatment, we created three models for each time point: (1) clinical variables, (2) adding clinically accessible biomarkers, e.g., neuron-specific enolase (NSE) and (3) adding research-grade biomarkers, e.g., neurofilament light (NFL). Patient outcome was the dichotomised Cerebral Performance Category (CPC) at six months; a good outcome was defined as CPC 1–2 whilst a poor outcome was defined as CPC 3–5. The area under the receiver operating characteristic curve (AUROC) was calculated for all test sets. Results AUROC remained below 90% when using only clinical variables throughout the first three days in the ICU. Adding clinically accessible biomarkers such as NSE, AUROC increased from 82 to 94% (p < 0.01). The prognostic accuracy remained excellent from day 1 to day 3 with an AUROC at approximately 95% when adding research-grade biomarkers. The models which included NSE after 72 h and NFL on any of the three days had a low risk of false-positive predictions while retaining a low number of false-negative predictions. Conclusions In this exploratory study, ANNs provided good to excellent prognostic accuracy in predicting neurological outcome in comatose patients post OHCA. The models which included NSE after 72 h and NFL on all days showed promising prognostic performance. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03505-9.
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Affiliation(s)
- Peder Andersson
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Skåne University Hospital, Lund, Sweden. .,Department of Intensive and Perioperative Care, Skåne University Hospital, Getingevägen 4, 222 41, LundLund, Sweden.
| | - Jesper Johnsson
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Lund, Sweden
| | - Ola Björnsson
- Department of Energy Sciences, Faculty of Engineering, Lund University, Lund, Sweden.,Centre for Mathematical Sciences, Mathematical Statistics, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy At the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute At UCL, London, UK
| | - Pascal Stammet
- Medical and Health Directorate, National Fire and Rescue Corps, 1, rue Robert Stumper, 2557, Luxembourg, Luxembourg
| | - Johan Undén
- Department of Clinical Sciences Malmö, Anaesthesia and Intensive Care, Lund University, Hallands Hospital Halmstad, Halland, Sweden
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy At the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Lund, Sweden
| | - Attila Frigyesi
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Skåne University Hospital, Lund, Sweden.,Centre for Mathematical Sciences, Mathematical Statistics, Lund University, Lund, Sweden
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Wiberg S, Holmgaard F, Blennow K, Nilsson JC, Kjaergaard J, Wanscher M, Langkilde AR, Hassager C, Rasmussen LS, Zetterberg H, Vedel AG. Associations between mean arterial pressure during cardiopulmonary bypass and biomarkers of cerebral injury in patients undergoing cardiac surgery: secondary results from a randomized controlled trial. Interact Cardiovasc Thorac Surg 2021; 32:229-235. [PMID: 33221914 PMCID: PMC8906782 DOI: 10.1093/icvts/ivaa264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/15/2020] [Accepted: 10/04/2020] [Indexed: 08/26/2023] Open
Abstract
OBJECTIVES Cardiac surgery is associated with risk of cerebral injury and mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) is suggested to be associated with cerebral injury. The 'Perfusion Pressure Cerebral Infarcts' (PPCI) trial randomized patients undergoing coronary artery bypass grafting (CABG) and/or aortic valve replacement to a MAP of 40-50 or 70-80 mmHg during CPB and found no difference in clinical or imaging outcomes between the groups. We here present PPCI trial predefined secondary end points, consisting of biomarkers of brain injury. METHODS Blood was collected from PPCI trial patients at baseline, 24 and 48 h after induction of anaesthesia and at discharge from the surgical ward. Blood was analysed for neuron-specific enolase, tau, neurofilament light and the glial marker glial fibrillary acidic protein. Linear mixed models were used to analyse differences in biomarker value changes from baseline between the 2 MAP allocation groups. RESULTS A total of 193 (98%) patients were included. We found no differences in biomarker levels over time from baseline to discharge between the 2 MAP allocation groups (PNSE = 0.14, PTau = 0.46, PNFL = 0.21, PGFAP = 0.13) and the result did not change after adjustment for age, sex and type of surgery. CONCLUSIONS We found no significant differences in levels of biomarkers of neurological injury in patients undergoing elective or subacute CABG and/or aortic valve replacement randomized to either a target MAP of 40-50 mmHg or a target MAP of 70-80 mmHg during CBP.
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Affiliation(s)
- Sebastian Wiberg
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Holmgaard
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jens C Nilsson
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael Wanscher
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Annika R Langkilde
- Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
- UK Dementia Research Institute at UCL, London, UK
| | - Anne Grønborg Vedel
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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DeKosky ST, Kochanek PM, Valadka AB, Clark RS, Chou SHY, Au AK, Horvat C, Jha RM, Mannix R, Wisniewski SR, Wintermark M, Rowell SE, Welch RD, Lewis L, House S, Tanzi RE, Smith DR, Vittor AY, Denslow ND, Davis MD, Glushakova OY, Hayes RL. Blood Biomarkers for Detection of Brain Injury in COVID-19 Patients. J Neurotrauma 2021; 38:1-43. [PMID: 33115334 PMCID: PMC7757533 DOI: 10.1089/neu.2020.7332] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus attacks multiple organs of coronavirus disease 2019 (COVID-19) patients, including the brain. There are worldwide descriptions of neurological deficits in COVID-19 patients. Central nervous system (CNS) symptoms can be present early in the course of the disease. As many as 55% of hospitalized COVID-19 patients have been reported to have neurological disturbances three months after infection by SARS-CoV-2. The mutability of the SARS-COV-2 virus and its potential to directly affect the CNS highlight the urgency of developing technology to diagnose, manage, and treat brain injury in COVID-19 patients. The pathobiology of CNS infection by SARS-CoV-2 and the associated neurological sequelae of this infection remain poorly understood. In this review, we outline the rationale for the use of blood biomarkers (BBs) for diagnosis of brain injury in COVID-19 patients, the research needed to incorporate their use into clinical practice, and the improvements in patient management and outcomes that can result. BBs of brain injury could potentially provide tools for detection of brain injury in COVID-19 patients. Elevations of BBs have been reported in cerebrospinal fluid (CSF) and blood of COVID-19 patients. BB proteins have been analyzed in CSF to detect CNS involvement in patients with infectious diseases, including human immunodeficiency virus and tuberculous meningitis. BBs are approved by the U.S. Food and Drug Administration for diagnosis of mild versus moderate traumatic brain injury and have identified brain injury after stroke, cardiac arrest, hypoxia, and epilepsy. BBs, integrated with other diagnostic tools, could enhance understanding of viral mechanisms of brain injury, predict severity of neurological deficits, guide triage of patients and assignment to appropriate medical pathways, and assess efficacy of therapeutic interventions in COVID-19 patients.
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Affiliation(s)
- Steven T. DeKosky
- McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, Department of Anesthesiology, Pediatrics, Bioengineering, and Clinical and Translational Science, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alex B. Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Robert S.B. Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sherry H.-Y. Chou
- Department of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alicia K. Au
- University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Division of Pediatric Critical Care, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ruchira M. Jha
- Departments of Critical Care Medicine, Neurology, Neurological Surgery, Clinical and Translational Science Institute, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rebekah Mannix
- Department of Pediatrics and Emergency Medicine, Harvard Medical School, Department of Medicine, Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Max Wintermark
- Department of Neuroradiology, Stanford University, Stanford, California, USA
| | - Susan E. Rowell
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert D. Welch
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Receiving Hospital/University Health Center, Detroit, Michigan, USA
| | - Lawrence Lewis
- Department of Emergency Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Stacey House
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rudolph E. Tanzi
- Genetics and Aging Research Unit, Massachusetts General Hospital, McCance Center for Brain Health, Massachusetts General Hospital, MassGeneral Institute for Neurodegenerative Diseases, Massachusetts General Hospital, Department of Neurology (Research), Massachusetts General Hospital, Department of Neurology, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Darci R. Smith
- Immunodiagnostics Department, Naval Medical Research Center, Biological Defense Research Directorate, Fort Detrick, Maryland, USA
| | - Amy Y. Vittor
- Division of Infectious Disease and Global Medicine, University of Florida, Emerging Pathogens Institute, Gainesville, Florida, USA
| | - Nancy D. Denslow
- Departments of Physiological Sciences and Biochemistry and Molecular Biology, University of Florida, Center for Environmental and Human Toxicology, Gainesville, Florida
| | - Michael D. Davis
- Department of Pediatrics, Wells Center for Pediatric Research/Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children at Indiana University, Indianapolis, Indiana, USA
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Soar J, Berg KM, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D'Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CWE, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O'Neil BJ, Otto Q, de Paiva EF, Parr MJA, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2020; 156:A80-A119. [PMID: 33099419 PMCID: PMC7576326 DOI: 10.1016/j.resuscitation.2020.09.012] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
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Fink EL, Clark RSB, Panigrahy A, Berger R, Wisnowski J, Bluml S, Maloney D, Rubin P, Haller T, Bayir H, Beers SR, Kochanek PM, Fabio A. Personalising Outcomes after Child Cardiac Arrest (POCCA): design and recruitment challenges of a multicentre, observational study. BMJ Open 2020; 10:e039323. [PMID: 33109667 PMCID: PMC7592297 DOI: 10.1136/bmjopen-2020-039323] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Blood and imaging biomarkers show promise in prognosticating outcomes after paediatric cardiac arrest in pilot studies. We describe the methods and early recruitment challenges and solutions for an ongoing multicentre (n=14) observational trial, Personalising Outcomes following Child Cardiac Arrest to validate clinical, blood and imaging biomarkers individually and together in a clinically relevant panel. METHODS AND ANALYSIS Children (n=164) between 48 hours and 17 years of age who receive chest compressions irrespective of provider, duration, or event location and are admitted to an intensive care unit are eligible. Blood samples will be taken on days 1-3 for the measurement of brain-focused biomarkers analysed to predict the outcome. Clinically indicated and timed brain MRI and spectroscopy biomarkers will be analysed to predict the outcome. The primary outcome for the trial is survival with favourable (Vineland Adaptive Behavioural Scale score >70) outcome at 1 year. Secondary outcomes include mortality and pre-event and postdischarge measures of emotional, cognitive, physical and family functioning and health-related quality of life. Early enrollment targets were not met due to prolonged regulatory and subcontract processes. Multiple, simultaneous interventions including modification to inclusion criteria, additional sites and site visits were implemented with successful improvement in recruitment. Study procedures including outcomes and biomarker analysis are ongoing. ETHICS AND DISSEMINATION Twelve of 14 sites will use the centralised Institutional Review Board (IRB) at the University of Pittsburgh (PRO14030712). Two sites will use individual IRBs: Children's Healthcare of Atlanta Institutional Review Board and Children's Hospital of Wisconsin IRB. Parents and/or guardians are consented and children assented (when possible) by the site Primary investigator (PI) or research coordinator for enrollment. Study findings will be disseminated through scientific conferences, peer-reviewed journal publications, public study website materials and invited lectures. TRIAL REGISTRATION NUMBER NCT02769026.
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Affiliation(s)
- Ericka L Fink
- Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Robert S B Clark
- Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ashok Panigrahy
- Radiology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rachel Berger
- Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jessica Wisnowski
- Radiology, USC Keck School of Medicine, Los Angeles, California, USA
| | - Stefan Bluml
- Radiology, USC Keck School of Medicine, Los Angeles, California, USA
| | - David Maloney
- Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pamela Rubin
- Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tamara Haller
- Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hulya Bayir
- Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sue R Beers
- Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Patrick M Kochanek
- Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anthony Fabio
- Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Li J, Gu Y, Li G, Wang L, Cheng X, Wang M, Zhao M. The Role of Hypothermia in Large Hemispheric Infarction: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:549872. [PMID: 33192981 PMCID: PMC7653189 DOI: 10.3389/fneur.2020.549872] [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: 04/07/2020] [Accepted: 09/18/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Hypothermia is used in the treatment of large hemispheric infarction (LHI); however, its role in outcomes for LHI patients remains ambiguous. This systematic review and meta-analysis was conducted to evaluate the effect of hypothermia on the outcomes of LHI patients. Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, China Biological Medicine Database, and clinical trials registers before September 21, 2018, and then scanned the reference lists. Randomized controlled trials that compared hypothermia with normothermia in LHI patients were included. Primary outcomes that we reviewed were mortality and neurological outcome. Adverse events during treatment were defined as secondary outcomes. We performed a meta-analysis to calculate pooled risk ratios (RRs), standardized mean differences (SMDs), and 95% confidence intervals (CIs) using fixed-effect models. Results: Three randomized controlled trials involving 131 participants were included. No statistically significant association was revealed between hypothermia and mortality (RR, 1.12; 95% CI, 0.76-1.65). There was significant association between hypothermia and good neurological outcome as assessed by modified Rankin Scale score (mRS of 0-3) of survivors (RR, 2.09; 95% CI, 1.14-3.82), and with neurological outcome by mRS (SMD, -0.54; 95% CI, -1.07 to -0.01). However, significant associations were found between hypothermia and gastrointestinal bleeding, gastric retention, electrolyte derangement, and shivering. No significant differences were detected in the incidence of developing herniation in the rewarming process, pneumonia, cardiac arrhythmia, hemorrhagic transformation, hyperglycemia, hypotension, acute kidney injury, and venous thrombotic events in LHI patients who underwent hypothermia compared with those who had normothermia. Conclusions: This meta-analysis suggested that hypothermia was not associated with mortality in LHI patients. However, it was associated with the improvement of neurological outcome, but with a higher risk of adverse events during treatment. Future studies are needed to demonstrate the efficacy and safety of hypothermia for LHI. The protocol for this systematic review was obtained from PROSPERO (registration number: CRD42018111761).
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Affiliation(s)
- Jing Li
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Yanghui Gu
- Department of Cardiology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Gang Li
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Lixin Wang
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaobin Cheng
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Min Wang
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Min Zhao
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Berg KM, Soar J, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D’Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CW, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O’Neil BJ, Otto Q, de Paiva EF, Parr MJ, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP, Issa M, Kleinman ME, Ristagno G, Arafeh J, Benoit JL, Chase M, Fischberg BL, Flores GE, Link MS, Ornato JP, Perman SM, Sasson C, Zelop CM. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S92-S139. [DOI: 10.1161/cir.0000000000000893] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This
2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Neuron-specific enolase and neuroimaging for prognostication after cardiac arrest treated with targeted temperature management. PLoS One 2020; 15:e0239979. [PMID: 33002033 PMCID: PMC7529296 DOI: 10.1371/journal.pone.0239979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/17/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Prognostication after cardiac arrest (CA) needs a multimodal approach, but the optimal method is not known. We tested the hypothesis that the combination of neuron-specific enolase (NSE) and neuroimaging could improve outcome prediction after CA treated with targeted temperature management (TTM). METHODS A retrospective observational cohort study was performed on patients who underwent at least one NSE measurement between 48 and 72 hr; received both a brain computed tomography (CT) scan within 24 hr and diffusion-weighted magnetic resonance imaging (DW-MRI) within 7 days after return of spontaneous circulation (ROSC); and were treated with TTM after out-of-hospital CA between 2009 and 2017 at the Seoul St. Mary's Hospital in Korea. The primary outcome was a poor neurological outcome at 6 months after CA, defined as a cerebral performance category of 3-5. RESULTS A total of 109 subjects underwent all three tests and were ultimately included in this study. Thirty-four subjects (31.2%) experienced good neurological outcomes at 6 months after CA. The gray matter to white matter attenuation ratio (GWR) was weakly correlated with the mean apparent diffusion coefficient (ADC), PV400 and NSE (Spearman's rho: 0.359, -0.362 and -0.263, respectively). NSE was strongly correlated with the mean ADC and PV400 (Spearman's rho: -0.623 and 0.666, respectively). Serum NSE had the highest predictive value among the single parameters (area under the curve (AUC) 0.912, sensitivity 70.7% for maintaining 100% specificity). The combination of a DWI parameter (mean ADC or PV400) and NSE had better prognostic performance than the combination of the CT parameter (GWR) and NSE. The addition of the GWR to a DWI parameter and NSE did not improve the prediction of neurological outcomes. CONCLUSION The GWR (≤ 24 hr) is weakly correlated with the mean ADC (≤ 7 days) and NSE (highest between 48 and 72 hr). The combination of a DWI parameter and NSE has better prognostic performance than the combination of the GWR and NSE. The addition of the GWR to a DWI parameter and NSE does not improve the prediction of neurological outcomes after CA treatment with TTM.
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Biomarkers of neuronal damage in saturation diving-a controlled observational study. Eur J Appl Physiol 2020; 120:2773-2784. [PMID: 32975632 PMCID: PMC7674315 DOI: 10.1007/s00421-020-04499-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 09/10/2020] [Indexed: 11/17/2022]
Abstract
Purpose A prospective and controlled observational study was performed to determine if the central nervous system injury markers glial fibrillary acidic protein (GFAp), neurofilament light (NfL) and tau concentrations changed in response to a saturation dive. Methods The intervention group consisted of 14 submariners compressed to 401 kPa in a dry hyperbaric chamber. They remained pressurized for 36 h and were then decompressed over 70 h. A control group of 12 individuals was used. Blood samples were obtained from both groups before, during and after hyperbaric exposure, and from the intervention group after a further 25–26 h. Results There were no statistically significant changes in the concentrations of GFAp, NfL and tau in the intervention group. During hyperbaric exposure, GFAp decreased in the control group (mean/median − 15.1/ − 8.9 pg·mL−1, p < 0.01) and there was a significant difference in absolute change of GFAp and NfL between the groups (17.7 pg·mL−1, p = 0.02 and 2.34 pg·mL−1, p = 0.02, respectively). Albumin decreased in the control group (mean/median − 2.74 g/L/ − 0.95 g/L, p = 0.02), but there was no statistically significant difference in albumin levels between the groups. In the intervention group, haematocrit and mean haemoglobin values were slightly increased after hyperbaric exposure (mean/median 2.3%/1.5%, p = 0.02 and 4.9 g/L, p = 0.06, respectively). Conclusion Hyperbaric exposure to 401 kPa for 36 h was not associated with significant increases in GFAp, NfL or tau concentrations. Albumin levels, changes in hydration or diurnal variation were unlikely to have confounded the results. Saturation exposure to 401 kPa seems to be a procedure not harmful to the central nervous system. Trial registration ClinicalTrials.gov NCT03192930.
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Moseby-Knappe M, Cronberg T. Blood biomarkers of brain injury after cardiac arrest - A dynamic field. Resuscitation 2020; 156:273-276. [PMID: 32946983 DOI: 10.1016/j.resuscitation.2020.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/07/2020] [Indexed: 01/05/2023]
Affiliation(s)
- Marion Moseby-Knappe
- Skåne University Hospital, Department of Clinical Sciences, Neurology, Lund, Sweden
| | - Tobias Cronberg
- Skåne University Hospital, Department of Clinical Sciences, Neurology, Lund, Sweden.
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Sandroni C, D'Arrigo S, Cacciola S, Hoedemaekers CWE, Kamps MJA, Oddo M, Taccone FS, Di Rocco A, Meijer FJA, Westhall E, Antonelli M, Soar J, Nolan JP, Cronberg T. Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 2020; 46:1803-1851. [PMID: 32915254 PMCID: PMC7527362 DOI: 10.1007/s00134-020-06198-w] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/15/2020] [Indexed: 12/17/2022]
Abstract
Purpose To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3–5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013–April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2–5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169) Electronic supplementary material The online version of this article (10.1007/s00134-020-06198-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sonia D'Arrigo
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Sofia Cacciola
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | - Marlijn J A Kamps
- Intensive Care Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Mauro Oddo
- Department of Intensive Care Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arianna Di Rocco
- Department of Public Health and Infectious Disease, Sapienza University, Rome, Italy
| | - Frederick J A Meijer
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Erik Westhall
- Department of ClinicalSciences, Clinical Neurophysiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jasmeet Soar
- Critical Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
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