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Gong AK, Oh SH, Jang J, Park KN, Kim HJ, Lee JY, Youn CS, Lim JY, Kim HJ, Bang HJ. Prognostic Implication of Ventricular Volumetry in Early Brain Computed Tomography after Cardiac Arrest. Diagnostics (Basel) 2024; 14:1701. [PMID: 39202189 PMCID: PMC11353943 DOI: 10.3390/diagnostics14161701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 09/03/2024] Open
Abstract
Brain swelling after cardiac arrest may affect brain ventricular volume. This study aimed to investigate the prognostic implications of ventricular volume on early thin-slice brain computed tomography (CT) after cardiac arrest. We measured the gray-to-white matter ratio (GWR) and the characteristics and volumes of the lateral, third, and fourth ventricles. The primary outcome was a poor 6-month neurological outcome. Of the 166 patients, 115 had a poor outcome. The fourth ventricle was significantly smaller in the poor outcome group (0.58 cm3 [95% CI, 0.43-0.80]) than in the good outcome group (0.74 cm3 [95% CI, 0.68-0.99], p < 0.001). Ventricular characteristics and other ventricular volumes did not differ between outcome groups. The area under the curve for the fourth ventricular volume was 0.68, comparable to 0.69 for GWR. Lower GWR (<1.09) and lower fourth ventricular volume (<0.41 cm3) predicted poor outcomes with 100% specificity and sensitivities of 8.7% (95% CI, 4.2-15.4) and 20.9% (95% CI, 13.9-29.4), respectively. Combining these measures improved the sensitivity to 25.2% (95% CI, 17.6-34.2). After adjusting for covariates, the fourth ventricular volume was independently associated with neurologic outcome. A marked decrease in fourth ventricular volume, with concomitant hypoattenuation on CT scans, more accurately predicted outcomes.
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Affiliation(s)
- Ae Kyung Gong
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (A.K.G.)
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (A.K.G.)
| | - Jinhee Jang
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (A.K.G.)
| | - Han Joon Kim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (A.K.G.)
| | - Ji Young Lee
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (A.K.G.)
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (A.K.G.)
| | - Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (A.K.G.)
| | - Hyo Jin Bang
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (A.K.G.)
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Beekman R, Gilmore EJ. Cerebral edema following cardiac arrest: Are all shades of gray equal? Resuscitation 2024; 198:110213. [PMID: 38636600 DOI: 10.1016/j.resuscitation.2024.110213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Rachel Beekman
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States.
| | - Emily J Gilmore
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
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You Y, Park JS, Min JH, Jeong W, Ahn HJ, In YN, Jeon SY, Lee JK, Kang C. Blood-brain barrier permeability for the first 24 hours in hypoxic-ischemic brain injury following cardiac arrest. Resuscitation 2024; 198:110150. [PMID: 38401708 DOI: 10.1016/j.resuscitation.2024.110150] [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: 09/26/2023] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND This study aimed to explore the changes in blood-brain barrier (BBB) permeability and intracranial pressure (ICP) for the first 24 h after the return of spontaneous circulation (ROSC) and their association with injury severity of cardiac arrest. METHODS This prospective study analysed the BBB permeability assessed using the albumin quotient (Qa) and ICP every 2 h for the first 24 h after ROSC. The injury severity of cardiac arrest was assessed using Pittsburgh Cardiac Arrest Category (PCAC) scores. The primary outcome was the time course of changes in the BBB permeability and ICP for the first 24 h after ROSC and their association with injury severity (PCAC scores of 1-4). RESULTS Qa and ICP were measured 274 and 197 times, respectively, in 32 enrolled patients. Overall, the BBB permeability increased progressively over time after ROSC, and then it increased significantly at 18 h after ROSC compared with the baseline. In contrast, the ICP revealed non-significant changes for the first 24 h after ROSC. The Qa in the PCAC 2 group was < 0.01, indicating normal or mild BBB disruption at all time points, whereas the PCAC 3 and 4 groups showed a significant increase in BBB permeability at 14 and 22 h, and 12 and 14 h after ROSC, respectively. CONCLUSION BBB permeability increased progressively over time for the first 24 h after ROSC despite post-resuscitation care, whereas ICP did not change over time. BBB permeability has an individual pattern when stratified by injury severity.
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Affiliation(s)
- Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong, Republic of Korea
| | - So Young Jeon
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jae Kwang Lee
- Department of Emergency Medicine, Konyang University Hospital, College of Medicine, Daejeon 35365, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea.
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In YN, Kim HI, Park JS, Kang C, You Y, Min JH, Lee D, Lee IH, Jeong HS, Lee BK, Lee JK. Association between quantitative analysis of cerebral edema using CT imaging and neurological outcomes in cardiac arrest survivors. Am J Emerg Med 2024; 78:22-28. [PMID: 38181542 DOI: 10.1016/j.ajem.2023.12.036] [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: 09/17/2023] [Revised: 12/10/2023] [Accepted: 12/22/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND To determine if the density distribution proportion of Hounsfield unit (HUdp) in head computed tomography (HCT) images can be used to quantitatively measure cerebral edema in survivors of out-of-hospital cardiac arrest (OHCA). METHODS This retrospective observational study included adult comatose OHCA survivors who underwent HCT within 6 h (first) and 72-96 h (second), all performed using the same CT scanner. Semi-automated quantitative analysis was used to identify differences in HUdp at specific HU ranges across the intracranial component based on neurological outcome. Cerebral edema was defined as the increased displacement of the sum of HUdp values (ΔHUdp) at a specific range between two HCT scans. Poor neurological outcome was defined as cerebral performance categories 3-5 at 6 months after OHCA. RESULTS Twenty-three (42%) out of 55 patients had poor neurological outcome. Significant HUdp differences were observed between good and poor neurological outcomes in the second HCT scan at HU = 1-14, 23-35, and 39-56 (all P < 0.05). Only the ΔHUdp = 23-35 range showed a significant increase and correlation in the poor neurological outcome group (4.90 vs. -0.72, P < 0.001) with the sum of decreases in the other two ranges (r = 0.97, P < 0.001). Multivariate logistic regression analysis demonstrated a significant association between ΔHUdp = 23-35 range and poor neurological outcomes (adjusted OR, 1.12; 95% CI: 1.02-1.24; P = 0.02). CONCLUSION In this cohort study, the increased displacement in ΔHUdp = 23-35 range is independently associated with poor neurological outcome and provides a quantitative assessment of cerebral edema formation in OHCA survivors.
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Affiliation(s)
- 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, Daejoen, Republic of Korea
| | - Ho Il Kim
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea.
| | - Changshin Kang
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, 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, Daejoen, Republic of Korea
| | - Dongyoung Lee
- Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
| | - In Ho Lee
- Department of Radiology, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Hye Seon Jeong
- Department of Neurology, Chungnam National University Hospital, 266, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Chonnam National Univesity Hospital, Gwangju, Republic of Korea
| | - Jae Kwang Lee
- Department of Emergency Medicine, Konyang University Hospital, College of Medicine, Republic of Korea
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Case NP, Callaway CW, Elmer J, Coppler PJ. Simple approach to quantify hypoxic-ischemic brain injury severity from computed tomography imaging files after cardiac arrest. Resuscitation 2024; 195:110050. [PMID: 37977348 PMCID: PMC10922650 DOI: 10.1016/j.resuscitation.2023.110050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Grey-white ratio (GWR) can estimate severity of cytotoxic cerebral edema secondary to hypoxic-ischemic brain injury after cardiac arrest and predict progression to death by neurologic criteria (DNC). Current approaches to calculating GWR are not standardized and have variable interrater reliability. We tested if measures of variance of brain density on early computed tomographic (CT) imaging after cardiac arrest could predict DNC. METHODS We performed a retrospective cohort study, identifying post-arrest patients treated between 2011 and 2020 at our single center. We extracted demographic data from our registry and Digital Imaging and Communication in Medicine (DICOM) files for each patient's first brain CT. We analyzed slices 15-20 of each DICOM, corresponding to the level of the basal ganglia while accommodating differences in patient anatomy. We extracted pixel arrays and converted the radiodensities to Hounsfield units (HU). To focus on brain tissue densities, we excluded HU > 60 and < 10. We calculated the variance of each patient's HU distribution and the difference between the means of a two-group Gaussian finite mixture model. We compared these novel metrics to existing measures of cerebral edema, then randomly divided our data into 80% training and 20% test sets and used logistic regression to predict DNC. RESULTS Of 1,133 included subjects, 457 (40%) were female, mean (standard deviation) age was 58 (16) years, and 115 (10%) progressed to DNC. CTs were obtained a median [interquartile range] of 4.2 [2.8-5.7] hours post-arrest. Our novel measures correlated weakly with GWR. HU variance, but not difference between mixture model means, differed significantly between subjects with and without sulcal or cistern effacement. GWR outperformed our novel measures in predicting progression to DNC with an area under the receiver operating characteristic curve (AUC) of 0.82, compared to HU variance (AUC = 0.73) and the difference between mixture model means (AUC = 0.56). CONCLUSION There are differences in the distribution of HU on post-arrest CT in patients with qualitative measures of cerebral edema. Current methods to quantify cerebral edema outperform simple measures of attenuation variance on early brain CT. Further analyses could investigate if these measures of variance, or other distributional characteristics of brain density, have improved predictive performance on brain CTs obtained later in the clinical course or derived from discrete regions of anatomical interest.
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Affiliation(s)
- Nicholas P Case
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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6
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Verhulst MMLH, Visser IM, Keijzer HM, de Kruijf NLM, Peters EJG, Wilbers T, Peelen RV, Hofmeijer J, Blans MJ. Additional predictive value of optic nerve sheath diameter for neurological prognosis after cardiac arrest: a prospective cohort study. Ultrasound J 2023; 15:46. [PMID: 38063930 PMCID: PMC10709263 DOI: 10.1186/s13089-023-00344-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/01/2023] [Indexed: 08/30/2024] Open
Abstract
BACKGROUND The goal is to estimate the additional value of ultrasonographic optic nerve sheath diameter (ONSD) measurement on days 1-3, on top of electroencephalography (EEG), pupillary light reflexes (PLR), and somatosensory evoked potentials (SSEP), for neurological outcome prediction of comatose cardiac arrest patients. We performed a prospective longitudinal cohort study in adult comatose patients after cardiac arrest. ONSD was measured on days 1-3 using ultrasound. Continuous EEG, PLR, and SSEP were acquired as standard care. Poor outcome was defined as cerebral performance categories 3-5 at 3-6 months. Logistic regression models were created for outcome prediction based on the established predictors with and without ONSD. Additional predictive value was assessed by increase in sensitivity for poor (at 100% specificity) and good outcome (at 90% specificity). RESULTS We included 100 patients, 54 with poor outcome. Mean ONSD did not differ significantly between patients with good and poor outcome. Sensitivity for predicting poor outcome increased by adding ONSD to EEG and SSEP from 25% to 41% in all patients and from 27% to 50% after exclusion of patients with non-neurological death. CONCLUSIONS ONSD on days 1-3 after cardiac arrest holds potential to add to neurological outcome prediction. TRIAL REGISTRATION clinicaltrials.gov, NCT04084054. Registered 10 September 2019, https://www. CLINICALTRIALS gov/study/NCT04084054 .
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Affiliation(s)
- Marlous M L H Verhulst
- Department of Neurology, Rijnstate Hospital, 6800 TA, Arnhem, The Netherlands.
- Department of Clinical Neurophysiology, Faculty of Science and Technology, University of Twente, 7522 NB, Enschede, The Netherlands.
| | - Iris M Visser
- Technical Medicine, University of Twente, 7522NB, Enschede, The Netherlands
- Department of Intensive Care Medicine, Rijnstate Hospital, 6800 TA, Arnhem, The Netherlands
| | - Hanneke M Keijzer
- Department of Neurology, Rijnstate Hospital, 6800 TA, Arnhem, The Netherlands
| | - Nicole L M de Kruijf
- Department of Neurology, Rijnstate Hospital, 6800 TA, Arnhem, The Netherlands
- Technical Medicine, University of Twente, 7522NB, Enschede, The Netherlands
| | - Erwin J G Peters
- Department of Intensive Care Medicine, Rijnstate Hospital, 6800 TA, Arnhem, The Netherlands
| | - Thom Wilbers
- Department of Intensive Care Medicine, Rijnstate Hospital, 6800 TA, Arnhem, The Netherlands
| | - Roel V Peelen
- Department of Intensive Care Medicine, Rijnstate Hospital, 6800 TA, Arnhem, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, 6800 TA, Arnhem, The Netherlands
- Department of Clinical Neurophysiology, Faculty of Science and Technology, University of Twente, 7522 NB, Enschede, The Netherlands
| | - Michiel J Blans
- Department of Intensive Care Medicine, Rijnstate Hospital, 6800 TA, Arnhem, The Netherlands
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Lascarrou JB, Ermel C, Cariou A, Laitio T, Kirkegaard H, Søreide E, Grejs AM, Reinikainen M, Colin G, Taccone FS, Le Gouge A, Skrifvars MB. Dysnatremia at ICU admission and functional outcome of cardiac arrest: insights from four randomised controlled trials. Crit Care 2023; 27:472. [PMID: 38041177 PMCID: PMC10693108 DOI: 10.1186/s13054-023-04715-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/30/2023] [Indexed: 12/03/2023] Open
Abstract
PURPOSE To evaluate the potential association between early dysnatremia and 6-month functional outcome after cardiac arrest. METHODS We pooled data from four randomised clinical trials in post-cardiac-arrest patients admitted to the ICU with coma after stable return of spontaneous circulation (ROSC). Admission natremia was categorised as normal (135-145 mmol/L), low, or high. We analysed associations between natremia category and Cerebral Performance Category (CPC) 1 or 2 at 6 months, with and without adjustment on the modified Cardiac Arrest Hospital Prognosis Score (mCAHP). RESULTS We included 1163 patients (581 from HYPERION, 352 from TTH48, 120 from COMACARE, and 110 from Xe-HYPOTHECA) with a mean age of 63 ± 13 years and a predominance of males (72.5%). A cardiac cause was identified in 63.6% of cases. Median time from collapse to ROSC was 20 [15-29] minutes. Overall, mean natremia on ICU admission was 137.5 ± 4.7 mmol/L; 211 (18.6%) and 31 (2.7%) patients had hyponatremia and hypernatremia, respectively. By univariate analysis, CPC 1 or 2 at 6 months was significantly less common in the group with hyponatremia (50/211 [24%] vs. 363/893 [41%]; P = 0.001); the mCAHP-adjusted odds ratio was 0.45 (95%CI 0.26-0.79, p = 0.005). The number of patients with hypernatremia was too small for a meaningful multivariable analysis. CONCLUSIONS Early hyponatremia was common in patients with ROSC after cardiac arrest and was associated with a poorer 6-month functional outcome. The mechanisms underlying this association remain to be elucidated in order to determine whether interventions targeting hyponatremia are worth investigating. Registration ClinicalTrial.gov, NCT01994772, November 2013, 21.
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Affiliation(s)
- Jean Baptiste Lascarrou
- Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, UR 4334, 44000, Nantes, France.
- Médecine Intensive Reanimation, University Hospital Centre, Nantes, France.
- AfterROSC Network, Nantes, France.
- Service de Médecine Intensive Reanimation, CHU Nantes, 30 Boulevard Jean Monet, 44093, Nantes Cedex 9, France.
| | - Cyrielle Ermel
- Médecine Intensive Reanimation, University Hospital Centre, Nantes, France
| | - Alain Cariou
- AfterROSC Network, Nantes, France
- Université de Paris Cité, INSERM, Paris Cardiovascular Research Centre, Paris, France
- Médecine Intensive Reanimation, AP-HP, CHU Cochin, Paris, France
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, University of Turku, Turku, Finland
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Anaesthesiology and Intensive Care, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Intensive Care Unit, Department of Anaesthesiology, Stavanger University Hospital and Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Anders M Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Gwenhael Colin
- AfterROSC Network, Nantes, France
- Médecine Intensive Reanimation, CHD Vendee, La Roche Sur Yon, France
| | - Fabio Silvio Taccone
- AfterROSC Network, Nantes, France
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Li Y, Wu T, Guo C. Inhibition of γδ T Cells Alleviates Blood-Brain Barrier in Cardiac Arrest and Cardiopulmonary Resuscitation in Mice. Mol Biotechnol 2023; 65:2061-2070. [PMID: 36944895 DOI: 10.1007/s12033-023-00705-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/14/2023] [Indexed: 03/23/2023]
Abstract
Ischemia/reperfusion (I/R) injury is the leading cause of death following cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). γδT cells are suggested to aggravate blood-brain barrier (BBB) injury in various pathological processes. We herein investigate the effects of γδT cells inhibitor (UC7-13D5) against I/R injury post-CA/CPR. C57BL/6 mice were subjected to CA through injection of KCL (70 μL of 0.5 mol/L) and cessation of mechanical ventilation followed by CPR. Flow cytometry was performed to measure the proportion of CD3-positive cells after intraperitoneal injection of 200 μg UC7-13D5 at 6 h, 24 h, and 48 h post-resuscitation into mice. Neurological scores and modified neurological severity scores were assessed to examine neurological functions. Brain edema was estimated via brain water content measurements. Immunohistochemistry of caspase-3 and immunofluorescence staining of claudin-1, ZO-1 and CD31 were performed to detect neuronal apoptosis, BBB integrity and angiogenesis. Microvascular morphology in the cortical area was assessed via H&E staining. Oxidative stress was determined by measuring malondialdehyde, myeloperoxidase, xanthine oxidase, superoxide dismutase, and glutathione peroxidase activities. Western blotting was performed to measure the protein levels of Nuclear factor-E2-related factor 2 (Nrf2) and Heme oxygenase-1 (HO-1). UC7-13D5 effectively depleted γδT cells. Inhibition of γδT cells improved neurological deficits and reduced brain edema post-CA/CPR. γδT cells depletion attenuated neuronal apoptosis, BBB disruption and oxidative stress and promoted angiogenesis following CA/CPR. Inhibition of γδT cells facilitated the activation of the Nrf2/HO-1 pathway in CA/CPR-induced mice. Inhibition of γδT cells alleviates neurological deficits and cerebral edema in mice with CA/CPR by inhibiting neuronal apoptosis, BBB disruption and oxidative stress, and promoting angiogenesis via activation of the Nrf2/HO-1 pathway.
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Affiliation(s)
- Yeqiu Li
- Department of Anesthesiology, Huazhong University of Science and Technology Union Dongxihu Hospital, People's Hospital of Wuhan Dongxihu District, Wuhan, 430040, Hubei, China
| | - Ting Wu
- Department of Anesthesiology, Hubei Hospital of Traditional Chinese Medicine, No. 4, Garden Hill, Yanzhi Road, Wuchang District, Wuhan, 430061, Hubei, China.
- Department of Anesthesiology, The Affiliated Hospital of Hubei Traditional Chinese Medicine University, Wuhan, 430061, China.
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, 430061, China.
| | - Cheng Guo
- Department of Anesthesiology, Hubei Hospital of Traditional Chinese Medicine, No. 4, Garden Hill, Yanzhi Road, Wuchang District, Wuhan, 430061, Hubei, China.
- Department of Anesthesiology, The Affiliated Hospital of Hubei Traditional Chinese Medicine University, Wuhan, 430061, China.
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, 430061, China.
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Yoon JA, Kang C, Park JS, You Y, Min JH, In YN, Jeong W, Ahn HJ, Lee IH, Jeong HS, Lee BK, Lee JK. Quantitative analysis of early apparent diffusion coefficient values from MRIs for predicting neurological prognosis in survivors of out-of-hospital cardiac arrest: an observational study. Crit Care 2023; 27:407. [PMID: 37880777 PMCID: PMC10599006 DOI: 10.1186/s13054-023-04696-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/19/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND This study aimed to quantitatively analyse ultra-early brain diffusion-weighted magnetic resonance imaging (DW-MRI) findings to determine the apparent diffusion coefficient (ADC) threshold associated with neurological outcomes in comatose survivors of out-of-hospital cardiac arrest (OHCA). METHODS This retrospective study included adult survivors of comatose OHCA who underwent DW-MRI imaging scans using a 3-T MRI scanner within 6 h of the return of spontaneous circulation (ROSC). We investigated the association between neurological outcomes and ADC values obtained through voxel-based analysis on DW-MRI. Additionally, we constructed multivariable logistic regression models with pupillary light reflex (PLR), serum neuron-specific enolase (NSE), and ADC values as independent variables to predict poor neurological outcomes. The primary outcome was poor neurological outcome 6 months after ROSC, determined by the Cerebral Performance Category 3-5. RESULTS Overall, 131 patients (26% female) were analysed, of whom 74 (57%) showed poor neurological outcomes. The group with a poor neurological outcome had lower mean whole brain ADC values (739.1 vs. 787.1 × 10-6 mm/s) and higher percentages of voxels with ADC below threshold in all ranges (250-1150) (all P < 0.001). The mean whole brain ADC values (area under the receiver operating characteristic curve [AUC] 0.83) and the percentage of voxels with ADC below 600 (AUC 0.81) had the highest sensitivity of 51% (95% confidence interval [CI] 39.4-63.1; cut-off value ≤ 739.2 × 10-6 mm2/s and > 17.2%, respectively) when the false positive rate (FPR) was 0%. In the multivariable model, which also included PLR, NSE, and mean whole brain ADC values, poor neurological outcome was predicted with the highest accuracy (AUC 0.91; 51% sensitivity). This model showed more accurate prediction and sensitivity at an FPR of 0% than did the combination of PLR and NSE (AUC 0.86; 30% sensitivity; P = 0.03). CONCLUSIONS In this cohort study, early voxel-based quantitative ADC analysis after ROSC was associated with poor neurological outcomes 6 months after cardiac arrest. The mean whole brain ADC value demonstrated the highest sensitivity when the FPR was 0%, and including it in the multivariable model improved the prediction of poor neurological outcomes.
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Affiliation(s)
- Jung A Yoon
- Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea.
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015, Republic of Korea.
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015, Republic of Korea
- Department of Emergency Medicine, Sejong Chungnam National University Hospital, Daejoen, Republic of Korea
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015, Republic of Korea
- Department of Emergency Medicine, Sejong Chungnam National University Hospital, Daejoen, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, Daejoen, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015, Republic of Korea
| | - In Ho Lee
- Department of Radiology, College of Medicine, Chungnam National University, 266, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hye Seon Jeong
- Department of Neurology, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jae Kwang Lee
- Department of Emergency Medicine, College of Medicine, Konyang University Hospital, Daejeon, Republic of Korea
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10
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Ko TS, Catennacio E, Shin SS, Stern J, Massey SL, Kilbaugh TJ, Hwang M. Advanced Neuromonitoring Modalities on the Horizon: Detection and Management of Acute Brain Injury in Children. Neurocrit Care 2023; 38:791-811. [PMID: 36949362 PMCID: PMC10241718 DOI: 10.1007/s12028-023-01690-9] [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: 06/02/2022] [Accepted: 01/31/2023] [Indexed: 03/24/2023]
Abstract
Timely detection and monitoring of acute brain injury in children is essential to mitigate causes of injury and prevent secondary insults. Increasing survival in critically ill children has emphasized the importance of neuroprotective management strategies for long-term quality of life. In emergent and critical care settings, traditional neuroimaging modalities, such as computed tomography and magnetic resonance imaging (MRI), remain frontline diagnostic techniques to detect acute brain injury. Although detection of structural and anatomical abnormalities remains crucial, advanced MRI sequences assessing functional alterations in cerebral physiology provide unique diagnostic utility. Head ultrasound has emerged as a portable neuroimaging modality for point-of-care diagnosis via assessments of anatomical and perfusion abnormalities. Application of electroencephalography and near-infrared spectroscopy provides the opportunity for real-time detection and goal-directed management of neurological abnormalities at the bedside. In this review, we describe recent technological advancements in these neurodiagnostic modalities and elaborate on their current and potential utility in the detection and management of acute brain injury.
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Affiliation(s)
- Tiffany S Ko
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, USA.
| | - Eva Catennacio
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Samuel S Shin
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Joseph Stern
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, USA
| | - Shavonne L Massey
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, USA
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11
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Coppler PJ, Elmer J, Doshi A, Guyette FX, Okubo M, Ratay C, Frisch AN, Steinberg A, Weissman A, Arias V, Drumheller BC, Flickinger KL, Faro J, Schmidhofer M, Rhinehart ZJ, Hansra BS, Fong-Isariyawongse J, Barot N, Baldwin ME, Murat Kaynar A, Darby JM, Shutter LA, Mettenburg J, Callaway CW. Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury. Resuscitation 2023; 188:109823. [PMID: 37164175 DOI: 10.1016/j.resuscitation.2023.109823] [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: 02/24/2023] [Revised: 04/17/2023] [Accepted: 05/01/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration. METHODS We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression. RESULTS We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time. CONCLUSIONS Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.
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Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ankur Doshi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cecelia Ratay
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adam N Frisch
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexis Steinberg
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Valerie Arias
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Byron C Drumheller
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - John Faro
- Department of Medicine, Soin Medical Center - Kettering Health, Beavercreek, OH, USA
| | - Mark Schmidhofer
- Department of Medicine, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Zachary J Rhinehart
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Barinder S Hansra
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Medicine, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Niravkumar Barot
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maria E Baldwin
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - A Murat Kaynar
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph M Darby
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lori A Shutter
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph Mettenburg
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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12
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Sandroni C, Skrifvars MB, Taccone FS. Brain monitoring after cardiac arrest. Curr Opin Crit Care 2023; 29:68-74. [PMID: 36762679 PMCID: PMC9994800 DOI: 10.1097/mcc.0000000000001023] [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] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW To describe the available neuromonitoring tools in patients who are comatose after resuscitation from cardiac arrest because of hypoxic-ischemic brain injury (HIBI). RECENT FINDINGS Electroencephalogram (EEG) is useful for detecting seizures and guiding antiepileptic treatment. Moreover, specific EEG patterns accurately identify patients with irreversible HIBI. Cerebral blood flow (CBF) decreases in HIBI, and a greater decrease with no CBF recovery indicates poor outcome. The CBF autoregulation curve is narrowed and right-shifted in some HIBI patients, most of whom have poor outcome. Parameters derived from near-infrared spectroscopy (NIRS), intracranial pressure (ICP) and transcranial Doppler (TCD), together with brain tissue oxygenation, are under investigation as tools to optimize CBF in patients with HIBI and altered autoregulation. Blood levels of brain biomarkers and their trend over time are used to assess the severity of HIBI in both the research and clinical setting, and to predict the outcome of postcardiac arrest coma. Neuron-specific enolase (NSE) is recommended as a prognostic tool for HIBI in the current postresuscitation guidelines, but other potentially more accurate biomarkers, such as neurofilament light chain (NfL) are under investigation. SUMMARY Neuromonitoring provides essential information to detect complications, individualize treatment and predict prognosis in patients with HIBI.
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario ‘Agostino Gemelli’- IRCCS
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Markus Benedikt Skrifvars
- Department of Emergency Medicine and Services, University of Helsinki
- Helsinki University Hospital, Helsinki, Finland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
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13
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Slovis JC, Volk L, Mavroudis C, Hefti M, Landis WP, Roberts AL, Delso N, Hallowell T, Graham K, Starr J, Lin Y, Melchior R, Nadkarni V, Sutton RM, Berg RA, Piel S, Morgan RW, Kilbaugh TJ. Pediatric Extracorporeal Cardiopulmonary Resuscitation: Development of a Porcine Model and the Influence of Cardiopulmonary Resuscitation Duration on Brain Injury. J Am Heart Assoc 2023; 12:e026479. [PMID: 36789866 PMCID: PMC10111482 DOI: 10.1161/jaha.122.026479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 12/08/2022] [Indexed: 02/16/2023]
Abstract
Background The primary objective was to develop a porcine model of prolonged (30 or 60 minutes) pediatric cardiopulmonary resuscitation (CPR) followed by 22- to 24-hour survival with extracorporeal life support, and secondarily to evaluate differences in neurologic injury. Methods and Results Ten-kilogram, 4-week-old female piglets were used. First, model development established the technique (n=8). Then, a pilot study was conducted (n=15). After 80% survival was achieved in the final 5 pilot animals, a proof-of-concept randomized study was completed (n=11). Shams (n=6) underwent anesthesia only. Severe neurological injury was determined by a composite score of mitochondrial function, neuropathology, and cerebral metabolism: scale of 0-6 (severe: >3). Among 15 piglets in the pilot study, overall survival was 10 (67%); of the final 5, overall survival was 4 (80%). Eleven piglets were then randomized to 60 (CPR60, n=5) or 30 minutes of CPR (CPR30, n=5); 1 animal was excluded from prerandomization for intra-abdominal hemorrhage (10/11, 91% survival). Three of 5 animals in the CPR60 group had severe neurological injury scores versus 1 of 5 in the CPR30 group (P=0.52). During ECMO, CPR60 animals had lower pH (CPR60: 7.4 [IQR 7.4-7.4] versus CPR30: 7.5 [IQR 7.4-7.5], P=0.022), higher lactate (CPR60: 6.8 [IQR 6.8-11] versus CPR30: 4.2 [IQR 4.1-4.3] mmol/L; P=0.012), and higher ICP (CPR60: 19.3 [IQR 11.7-29.3] versus CPR30: 7.9 [IQR 6.7-9.3] mm Hg; P=0.037). Both groups had greater mitochondrial injury than shams (CPR60: P<0.001; CPR30: P<0.001). CPR60 did not differ from CPR30 in mitochondrial respiration, neuropathology, or cerebral metabolism. Conclusions A pediatric porcine model of extracorporeal cardiopulmonary resuscitation after 60 and 30 minutes of CPR consistently resulted in 24-hour survival with more severe lactic acidosis in the 60-minute cohort.
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Affiliation(s)
- Julia C Slovis
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Lindsay Volk
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Surgery Robert Wood Johnson University Hospital New Brunswick NJ
| | - Constantine Mavroudis
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Surgery, Division of Cardiothoracic Surgery Children's Hospital of Philadelphia Philadelphia PA
| | - Marco Hefti
- Department of Pathology University of Iowa Carver College of Medicine Iowa City IA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Anna L Roberts
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Nile Delso
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Thomas Hallowell
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Jonathan Starr
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Yuxi Lin
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Richard Melchior
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Sarah Piel
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
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14
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Hinduja A, Gokun Y, Ibekwe E, Senay B, Elmer J. Risk factors for development of cerebral edema following cardiac arrest. Resuscitation 2022; 181:297-303. [PMID: 36280215 DOI: 10.1016/j.resuscitation.2022.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cerebral edema following cardiac arrest is a well-known complication of resuscitation and portends a poor outcome. We identified predictors of post-cardiac arrest cerebral edema and tested the association of cerebral edema with discharge outcome. METHODS We performed a retrospective chart review including patients admitted at a single center between January 2015-March 2020 following resuscitation from in-hospital and out-of-hospital cardiac arrest who had head computed tomography imaging. Our primary outcome was moderate-to-severe cerebral edema, which we defined as loss of grey-white differentiation with effacement of the basal and ambient cisterns and radiographic evidence of uncal herniation. We used logistic regression to test associations of demographic information, clinical predictors and comorbidities with moderate-severe cerebral edema. RESULTS We identified 727 patients who met the inclusion criteria, of whom 102 had moderate-to-severe cerebral edema. We identified six independent predictors of moderate-to-severe cerebral edema: younger age, prolonged arrest duration, pulseless electrical activity/asystole as initial rhythm, unwitnessed cardiac arrest, hyperglycemia on admission, and lower Glasgow coma score on presentation. Of patients with moderate-to-severe cerebral edema, 2% survived to discharge, 56% had withdrawal of life-sustaining therapies and 42% progressed to death by neurological criteria. CONCLUSIONS Our study identified several risk factors associated with the development of cerebral edema following cardiac arrest. Further studies are needed to determine the benefits of early interventions in these high-risk patients.
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Affiliation(s)
- Archana Hinduja
- Department of Neurology, The Ohio State University, Columbus, OH, United States.
| | - Yevgeniya Gokun
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH, United States
| | - Elochukwu Ibekwe
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Blake Senay
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Jonathan Elmer
- Department of Emergency Medicine, Critical Care Medicine and Neurology, University of Pittsburgh, PA, United States
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15
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Seder DB, Ryzhov S. Therapeutic opportunities for cerebral edema after resuscitation. Resuscitation 2022; 181:168-169. [PMID: 36423738 DOI: 10.1016/j.resuscitation.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Affiliation(s)
- David B Seder
- Maine Medical Center Department of Critical Care Services, Portland, ME, USA; MaineHealth Institute for Research, Scarborough, ME, USA
| | - Sergey Ryzhov
- Maine Medical Center Department of Critical Care Services, Portland, ME, USA; MaineHealth Institute for Research, Scarborough, ME, USA
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16
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Paul M, Benghanem S, Merceron S, Bellut H, Dumas F, Henry A, Bruneel F, Bedos JP, Cariou A, Legriel S. Cerebrospinal fluid features in comatose survivors of cardiac arrest: A pilot study. PLoS One 2022; 17:e0270954. [PMID: 35881643 PMCID: PMC9321437 DOI: 10.1371/journal.pone.0270954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/21/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Lumbar puncture is among the investigations used to identify various neurological conditions, including some that can cause cardiac arrest (CA). However, CA per se may alter cerebrospinal fluid (CSF) characteristics. Few studies have investigated CSF findings after CA. In this descriptive work, we assessed the frequency and risk factors of abnormal CSF findings after CA and the contribution of CSF analysis to the etiological diagnosis. MATERIALS AND METHODS We retrospectively studied data from prospectively established databases of consecutive patients who were admitted to two French ICUs in 2007-2016 with sustained return of spontaneous circulation (ROSC) after CA and who underwent lumbar puncture as an etiological investigation. RESULTS Of 1984 patients with sustained ROSC, 55 (2.7%) underwent lumbar puncture and were included. Lumbar puncture identified a neurological cause of CA in 2/55 (3.6%) patients. Nonspecific CSF abnormalities were noted in 37/53 (69.8%) patients. By multivariate analysis, postresuscitation shock was positively associated with CSF abnormalities (OR, 6.92; 95% confidence interval [95%CI], 1.62-37.26; P = 0.013). A no-flow time above 6 minutes (OR, 0.19; 95%CI, 0.03-1.11; P = 0.076) and a respiratory cause of CA (OR, 2.91; 95%CI, 0.53-23.15; P = 0.24) were not statistically associated with CSF abnormalities. Nonspecific CSF abnormalities were not significantly associated with poor outcomes (Cerebral Performance Category ≥3; P = 0.06). CONCLUSIONS Lumbar puncture, although infrequently performed, may contribute to the etiological diagnosis of CA, albeit rarely. Nonspecific CSF abnormalities seem common after CA, notably with postresuscitation shock, and may be related to blood-brain barrier disruption. These findings may help to interpret CSF findings after CA. Further studies are warranted to assess our results.
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Affiliation(s)
- Marine Paul
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
- AfterROSC Study Group, Paris, France
| | - Sarah Benghanem
- Intensive Care Unit, Cochin Hospital, Paris, France
- Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France
| | - Sybille Merceron
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Hugo Bellut
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Florence Dumas
- Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France
- Emergency Department, Cochin Hospital, Paris, France
- Université de Paris, PARCC, INSERM, Paris, France
- Paris Sudden-Death-Expertise-Centre, Paris, France
| | - Amandine Henry
- Microbiology Department, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Fabrice Bruneel
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Jean-Pierre Bedos
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
| | - Alain Cariou
- AfterROSC Study Group, Paris, France
- Intensive Care Unit, Cochin Hospital, Paris, France
- Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France
- Université de Paris, PARCC, INSERM, Paris, France
- Paris Sudden-Death-Expertise-Centre, Paris, France
| | - Stéphane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles—Site André Mignot, Le Chesnay, France
- AfterROSC Study Group, Paris, France
- University Paris-Saclay, UVSQ, INSERM, CESP, PsyDev Team, Villejuif, France
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17
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Beekman R, Crawford A, Mazurek MH, Prabhat AM, Chavva IR, Parasuram N, Kim N, Kim JA, Petersen N, de Havenon A, Khosla A, Honiden S, Miller PE, Wira C, Daley J, Payabvash S, Greer DM, Gilmore EJ, Taylor Kimberly W, Sheth KN. Bedside monitoring of hypoxic ischemic brain injury using low-field, portable brain magnetic resonance imaging after cardiac arrest. Resuscitation 2022; 176:150-158. [PMID: 35562094 PMCID: PMC9746653 DOI: 10.1016/j.resuscitation.2022.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/25/2022] [Accepted: 05/03/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Assessment of brain injury severity is critically important after survival from cardiac arrest (CA). Recent advances in low-field MRI technology have permitted the acquisition of clinically useful bedside brain imaging. Our objective was to deploy a novel approach for evaluating brain injury after CA in critically ill patients at high risk for adverse neurological outcome. METHODS This retrospective, single center study involved review of all consecutive portable MRIs performed as part of clinical care for CA patients between September 2020 and January 2022. Portable MR images were retrospectively reviewed by a blinded board-certified neuroradiologist (S.P.). Fluid-inversion recovery (FLAIR) signal intensities were measured in select regions of interest. RESULTS We performed 22 low-field MRI examinations in 19 patients resuscitated from CA (68.4% male, mean [standard deviation] age, 51.8 [13.1] years). Twelve patients (63.2%) had findings consistent with HIBI on conventional neuroimaging radiology report. Low-field MRI detected findings consistent with HIBI in all of these patients. Low-field MRI was acquired at a median (interquartile range) of 78 (40-136) hours post-arrest. Quantitatively, we measured FLAIR signal intensity in three regions of interest, which were higher amongst patients with confirmed HIBI. Low-field MRI was completed in all patients without disruption of intensive care unit equipment monitoring and no safety events occurred. CONCLUSION In a critically ill CA population in whom MR imaging is often not feasible, low-field MRI can be deployed at the bedside to identify HIBI. Low-field MRI provides an opportunity to evaluate the time-dependent nature of MRI findings in CA survivors.
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Affiliation(s)
- Rachel Beekman
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Anna Crawford
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Mercy H Mazurek
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Anjali M Prabhat
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Isha R Chavva
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Nethra Parasuram
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Noah Kim
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Jennifer A Kim
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Nils Petersen
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Akhil Khosla
- Department of Pulmonary Critical Care, Yale School of Medicine, New Haven, CT, USA
| | - Shyoko Honiden
- Department of Pulmonary Critical Care, Yale School of Medicine, New Haven, CT, USA
| | - P Elliott Miller
- Section of Cardiology, Yale School of Medicine, New Haven, CT, USA
| | - Charles Wira
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - James Daley
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - David M Greer
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Emily J Gilmore
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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18
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Cho EJ, Lee MS, Kwon WY, Shin J, Suh GJ, Jung YS, Song WJ, Yeo G, Jo YH. Hypernatremia is associated with poor long-term neurological outcomes in out-of-hospital cardiac arrest survivors. Am J Emerg Med 2022; 59:30-36. [PMID: 35772225 DOI: 10.1016/j.ajem.2022.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 05/20/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Brain oedema after cardiac arrest is strongly associated with poor neurological outcomes. Excessive sodium supplementation may increase serum osmolarity and facilitate brain oedema development in cardiac arrest survivors. We aimed to investigate the association of serum sodium levels with long-term neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors. METHODS This retrospective observational study used a multicentre prospective cohort registry of OHCA survivors collected between December 2013 and February 2018. We analyzed the association of serum sodium levels at the return of spontaneous circulation (ROSC) (Sodium 0H) and at 24 h after ROSC (Sodium 24H) with 1-year neurological outcomes in OHCA survivors. Patients with 1-year cerebral performance categories (CPC) 1 and 2 were included in the good outcome group while those with CPC 3, 4, and 5 were included in the poor outcome group. RESULTS Among 277 patients, 84 (30.3%) and 193 (69.7%) were in the good and poor outcome groups, respectively. Compared with the good outcome group, the poor outcome group showed significantly higher Sodium 24H levels (140 mEq/L vs. 137.4 mEq/L, p < 0.001). Increased serum sodium levels per 1 mEq/L increased the risk of poor 1-year CPC by 13% (adjusted odds ratio = 1.13; 95% CI, 1.04⎼1.23; p = 0.004). CONCLUSIONS Relatively high Sodium 24H levels showed a strong and independent association with poor long-term neurological outcomes in OHCA survivors. These findings may be applied in therapeutic strategies for improving neurological outcomes in OHCA survivors.
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Affiliation(s)
- Eun Joo Cho
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Min Sung Lee
- Medical Research Team, Medical AI, 163 Yangjaecheon-ro, Gangnam-gu, Seoul, Republic of Korea.
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea.
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Yoon Sun Jung
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Won Ji Song
- Department of Dermatology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Gyeongyeon Yeo
- Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
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19
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Krawiec C, Mysore MR, Mathur M, Fang X, Zhou S, Thomas NJ, Nakagawa TA. Impact of the Updated Guideline for Pediatric Brain Death Determination on Current Practice. J Child Neurol 2022; 37:553-561. [PMID: 35603748 PMCID: PMC9177504 DOI: 10.1177/08830738221047668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: A guideline to determine pediatric brain death was updated in 2011. It is unknown how pediatric intensivists have accepted and adopted the revised guideline into clinical practice. Methods: We surveyed US pediatric critical care attending physicians July 2013 to September 2013 and February 2020 to May 2020. Brain death testing practices and utilization of the 2011 pediatric and neonatal brain death guideline were assessed. Results: The 2020 respondents found that the revised pediatric brain death guideline were useful in clinical practice (93.7% vs 83.3%, P = .0484) and provided more consistency and clarity (73.2% vs 63.1%, P = .0462) when compared to 2013 respondents. Conclusion: This study demonstrates that with defined criteria, survey participants reported increased clarity and consistency. Findings from our study indicate that in clinical practice there is no significant deviation from the minimum requirements to determine brain death in children as outlined in the 2011 guideline.
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Affiliation(s)
- Conrad Krawiec
- Penn State Children’s Hospital, Pediatric Critical Care Medicine, Department of Pediatrics, 500 University Drive, Hershey, PA, USA
| | - Mohan R. Mysore
- Pediatric Critical Care, Boys Town National Research Hospital, Boys Town, NE, USA
| | - Mudit Mathur
- Pediatric Critical Care, Southern California Permanente Medical Group, Kaiser Permanente School of Medicine, Pasadena, CA, USA
| | - Xinying Fang
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Shouhao Zhou
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Neal J. Thomas
- Penn State Children’s Hospital, Pediatric Critical Care Medicine, Department of Pediatrics, 500 University Drive, Hershey, PA, USA,Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Thomas A. Nakagawa
- Department of Pediatrics, Division of Critical Care Medicine, University of Florida College of Medicine. Jacksonville, FL, USA
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20
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Kulpanowski AM, Copen WA, Hancock BL, Rosenthal ES, Schoenfeld DA, Dodelson JA, Edlow BL, Kimberly WT, Amorim E, Westover MB, Ning MM, Schaefer PW, Malhotra R, Giacino JT, Greer DM, Wu O. Severe cerebral edema in substance-related cardiac arrest patients. Resuscitation 2022; 173:103-111. [PMID: 35149137 PMCID: PMC9282938 DOI: 10.1016/j.resuscitation.2022.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 01/01/2022] [Accepted: 01/31/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Studies of neurologic outcomes have found conflicting results regarding differences between patients with substance-related cardiac arrests (SRCA) and non-SRCA. We investigate the effects of SRCA on severe cerebral edema development, a neuroimaging intermediate endpoint for neurologic injury. METHODS 327 out-of-hospital comatose cardiac arrest patients were retrospectively analyzed. Demographics and baseline clinical characteristics were examined. SRCA categorization was based on admission toxicology screens. Severe cerebral edema classification was based on radiology reports. Poor clinical outcomes were defined as discharge Cerebral Performance Category scores > 3. RESULTS SRCA patients (N = 86) were younger (P < 0.001), and more likely to have non-shockable rhythms (P < 0.001), be unwitnessed (P < 0.001), lower Glasgow Coma Scale scores (P < 0.001), absent brainstem reflexes (P < 0.05) and develop severe cerebral edema (P < 0.001) than non-SRCA patients (N = 241). Multivariable analyses found younger age (P < 0.001), female sex (P = 0.008), non-shockable rhythm (P = 0.01) and SRCA (P = 0.05) to be predictors of severe cerebral edema development. Older age (P < 0.001), non-shockable rhythm (P = 0.02), severe cerebral edema (P < 0.001), and absent pupillary light reflexes (P = 0.004) were predictors of poor outcomes. SRCA patients had higher proportion of brain deaths (P < 0.001) compared to non-SRCA patients. CONCLUSIONS SRCA results in higher rates of severe cerebral edema development and brain death. The absence of statistically significant differences in discharge outcomes or survival between SRCA and non-SRCA patients may be related to the higher rate of withdrawal of life-sustaining treatment (WLST) in the non-SRCA group. Future neuroprognostic studies may opt to include neuroimaging markers as intermediate measures of neurologic injury which are not influenced by WLST decisions.
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Affiliation(s)
- Annelise M Kulpanowski
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States
| | - William A Copen
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Brandon L Hancock
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - David A Schoenfeld
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, United States
| | - Jacob A Dodelson
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States
| | - Brian L Edlow
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Edilberto Amorim
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Ming Ming Ning
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Pamela W Schaefer
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Rajeev Malhotra
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, United States
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States
| | - David M Greer
- Department of Neurology, Boston University and Boston Medical Center, Boston, MA, United States
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States.
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21
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Zhou F, Wang H, Jian M, Wang Z, He Y, Duan H, Gan L, Cao Y. Gray-White Matter Ratio at the Level of the Basal Ganglia as a Predictor of Neurologic Outcomes in Cardiac Arrest Survivors: A Literature Review. Front Med (Lausanne) 2022; 9:847089. [PMID: 35372375 PMCID: PMC8967346 DOI: 10.3389/fmed.2022.847089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/09/2022] [Indexed: 02/05/2023] Open
Abstract
Loss of gray-white matter discrimination is the primary early imaging finding within of cranial computed tomography in cardiac arrest survivors, and this has been also regarded as a novel predictor for evaluating neurologic outcome. As displayed clearly on computed tomography and based on sensitivity to hypoxia, the gray-white matter ratio at basal ganglia (GWR-BG) region was frequently detected to assess the neurologic outcome by several studies. The specificity of GWR-BG is 72.4 to 100%, while the sensitivity is significantly different. Herein we review the mechanisms mediating cerebral edema following cardiac arrest, demonstrate the determination procedures with respect to GWR-BG, summarize the related researches regarding GWR-BG in predicting neurologic outcomes within cardiac arrest survivors, and discuss factors associated with predicting the accuracy of this methodology. Finally, we describe the effective measurements to increase the sensitivity of GWR-BG in predicting neurologic outcome.
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Affiliation(s)
- Fating Zhou
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hongxia Wang
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Mengyao Jian
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyuan Wang
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yarong He
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Haizhen Duan
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Gan
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Cao
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
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22
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Schick A, Prekker ME, Kempainen RR, Mulder M, Moore J, Evans D, Hall J, Rodinm H, Larson J, Caraganis A. Association of hypoxic ischemic brain injury on early CT after out of hospital cardiac arrest with neurologic outcome. Am J Emerg Med 2022; 54:257-262. [DOI: 10.1016/j.ajem.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 02/02/2023] Open
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23
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Intracranial Pressure Patterns and Neurological Outcomes in Out-of-Hospital Cardiac Arrest Survivors after Targeted Temperature Management: A Retrospective Observational Study. J Clin Med 2021; 10:jcm10235697. [PMID: 34884400 PMCID: PMC8658348 DOI: 10.3390/jcm10235697] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/27/2021] [Accepted: 12/02/2021] [Indexed: 11/25/2022] Open
Abstract
We aimed to investigate intracranial pressure (ICP) changes over time and the neurologic prognosis for out-of-hospital cardiac arrest (OHCA) survivors who received targeted temperature management (TTM). ICP was measured immediately after return of spontaneous circulation (ROSC) (day 1), then at 24 h (day 2), 48 h (day 3), and 72 h (day 4), through connecting a lumbar drain catheter to a manometer or a LiquoGuard machine. Neurological outcomes were determined at 3 months after ROSC, and a poor neurological outcome was defined as Cerebral Performance Category 3–5. Of the 91 patients in this study (males, n = 67, 74%), 51 (56%) had poor neurological outcomes. ICP was significantly higher in the poor outcome group at each time point except day 4. ICP elevation was highest between days 2 and 3 in the good outcome group, and between days 1 and 2 in the poor outcome group. However, there was no difference in total ICP elevation between the poor and good outcome groups (3.0 vs. 3.1; p = 0.476). All OHCA survivors who had received TTM had elevated ICP, regardless of neurologic prognosis. However, the changing pattern of ICP levels differed depending on the neurological outcome.
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24
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Kang C, Jeong W, Park JS, You Y, Min JH, Cho YC, Ahn HJ, In YN, Lee IH. Different Stratification of Physiological Factors Affecting Cerebral Perfusion Pressure in Hypoxic-Ischemic Brain Injury after Cardiac Arrest According to Visible or Non-Visible Primary Brain Injury: A Retrospective Observational Study. J Clin Med 2021; 10:jcm10225385. [PMID: 34830665 PMCID: PMC8625895 DOI: 10.3390/jcm10225385] [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: 09/12/2021] [Revised: 11/04/2021] [Accepted: 11/16/2021] [Indexed: 12/05/2022] Open
Abstract
We aimed to explore the stratification of physiological factors affecting cerebral perfusion pressure, including arterial oxygen tension, arterial carbon dioxide tension, mean arterial pressure, intracranial pressure (ICP), and blood-brain barrier (BBB) status, with respect to primary or secondary brain injury (PBI or SBI) after out-of-hospital cardiac arrest (OHCA). Among the retrospectively enrolled 97 comatose OHCA survivors undergoing post-cardiac arrest (PCA) care, 46 (47.4%) with already established PBI (high signal intensity (HSI) on diffusion-weighted imaging (DWI) had higher ICP (p = 0.02) and poorer BBB status (p < 0.01) than the non-HSI group. On subgroup analysis within the non-HSI group to exclude the confounding effect of already established PBI, 40 (78.4%) patients with good neurological outcomes had lower ICP at 24 h (11.0 vs. 16.0 mmHg, p < 0.01) and more stable BBB status (p = 0.17 in pairwise comparison) compared to those with poor neurological outcomes, despite the non-significant differences in other physiological factors. OHCA survivors with HSI on DWI showed significantly higher ICP and poorer BBB status at baseline before PCA care than those without HSI. Despite the negative DWI findings before PCA care, OHCA survivors have a cerebral penumbra at risk for potentially leading the poor neurological outcome from unsuppressed SBI, which may be associated with increased ICP and BBB permeability.
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Affiliation(s)
- Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
- Correspondence: ; Tel.: +82-42-280-6001
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20 Bodeum 7-ro, Sejong 30099, Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20 Bodeum 7-ro, Sejong 30099, Korea
| | - In Ho Lee
- Department of Radiology, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea;
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25
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Jha RM, Rani A, Desai SM, Raikwar S, Mihaljevic S, Munoz-Casabella A, Kochanek PM, Catapano J, Winkler E, Citerio G, Hemphill JC, Kimberly WT, Narayan R, Sahuquillo J, Sheth KN, Simard JM. Sulfonylurea Receptor 1 in Central Nervous System Injury: An Updated Review. Int J Mol Sci 2021; 22:11899. [PMID: 34769328 PMCID: PMC8584331 DOI: 10.3390/ijms222111899] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 12/17/2022] Open
Abstract
Sulfonylurea receptor 1 (SUR1) is a member of the adenosine triphosphate (ATP)-binding cassette (ABC) protein superfamily, encoded by Abcc8, and is recognized as a key mediator of central nervous system (CNS) cellular swelling via the transient receptor potential melastatin 4 (TRPM4) channel. Discovered approximately 20 years ago, this channel is normally absent in the CNS but is transcriptionally upregulated after CNS injury. A comprehensive review on the pathophysiology and role of SUR1 in the CNS was published in 2012. Since then, the breadth and depth of understanding of the involvement of this channel in secondary injury has undergone exponential growth: SUR1-TRPM4 inhibition has been shown to decrease cerebral edema and hemorrhage progression in multiple preclinical models as well as in early clinical studies across a range of CNS diseases including ischemic stroke, traumatic brain injury, cardiac arrest, subarachnoid hemorrhage, spinal cord injury, intracerebral hemorrhage, multiple sclerosis, encephalitis, neuromalignancies, pain, liver failure, status epilepticus, retinopathies and HIV-associated neurocognitive disorder. Given these substantial developments, combined with the timeliness of ongoing clinical trials of SUR1 inhibition, now, another decade later, we review advances pertaining to SUR1-TRPM4 pathobiology in this spectrum of CNS disease-providing an overview of the journey from patch-clamp experiments to phase III trials.
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Affiliation(s)
- Ruchira M. Jha
- Department of Neurology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (R.M.J.); (S.M.D.)
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Anupama Rani
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Shashvat M. Desai
- Department of Neurology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (R.M.J.); (S.M.D.)
| | - Sudhanshu Raikwar
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Sandra Mihaljevic
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Amanda Munoz-Casabella
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA;
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Joshua Catapano
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Ethan Winkler
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy;
- Neurointensive Care Unit, Department of Neuroscience, San Gerardo Hospital, ASST—Monza, 20900 Monza, Italy
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA 94143, USA;
| | - W. Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Raj Narayan
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY 11549, USA;
| | - Juan Sahuquillo
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain;
- Neurotraumatology and Neurosurgery Research Unit, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
- Department of Neurosurgery, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, School of Medicine, Yale University, New Haven, CT 06510, USA;
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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26
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Richter J, Sklienka P, Chatterjee N, Maca J, Zahorec R, Burda M. Elevated jugular venous oxygen saturation after cardiac arrest. Resuscitation 2021; 169:214-219. [PMID: 34678332 DOI: 10.1016/j.resuscitation.2021.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/28/2021] [Accepted: 10/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We performed a retrospective analysis of our earlier study on cerebral oxygenation monitoring by jugular venous oximetry (SjvO2) in patients of out-of-hospital cardiac arrest (OHCA). The study was focused on high SjvO2 values (≥75%) and their association with neurological outcomes and serum neuron-specific enolase (NSE) concentration. METHOD Forty OHCA patients were divided into (i) high (Group I), (ii) normal (Group II), and (iii) low (Group III) SjvO2, with the mean SjvO2 ≥ 75%, 55-74% and <55% respectively. The neurological outcome was evaluated using the Cerebral Performance Category scale (CPC) on the 90th day after cardiac arrest (post-CA). NSE concentration was determined after ICU admission and then at 24, 48, and 72 hours (h) post-CA. RESULTS High mean SjvO2 occurred in 67% of patients, while no patients had low mean SjvO2. The unfavourable outcome was significantly more common in Group I than Group II (74% versus 23%, p < 0.01). Group I patients had significantly higher median NSE than Group II at 48 and 72 h post-CA. A positive correlation was found between SjvO2 and PaCO2. Each 1 kPa increase in CO2 led to an increase of SjvO2 by 2.2 %+/-0.66 (p < 0.01) in group I and by 5.7%+/-1.36 (p < 0.0001) in group II. There was no correlation between SjvO2 and MAP or SjvO2 and PaO2. CONCLUSION High mean SjvO2 are often associated with unfavourable outcomes and high NSE at 48 and 72 hours post-CA. Not only low but also high SjvO2 values may require therapeutic intervention.
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Affiliation(s)
- Jaromir Richter
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic.
| | - Peter Sklienka
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Nilay Chatterjee
- Department of Anaesthetics, Yeovil Hospital, Yeovil, United Kingdom
| | - Jan Maca
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic; Department of Intensive Care Medicine and Forensic Studies, Institute of Physiology and Pathophysiology Faculty Of Medicine, University of Ostrava, Czech Republic
| | - Roman Zahorec
- Second Department of Anesthesiology and Intensive Medicine, Medical School, Comenius University, Bratislava, Slovak Republic
| | - Michal Burda
- Institute for Research and Applications of Fuzzy Modeling, University of Ostrava, Czech Republic
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27
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Perkins GD, Callaway CW, Haywood K, Neumar RW, Lilja G, Rowland MJ, Sawyer KN, Skrifvars MB, Nolan JP. Brain injury after cardiac arrest. Lancet 2021; 398:1269-1278. [PMID: 34454687 DOI: 10.1016/s0140-6736(21)00953-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/16/2022]
Abstract
As more people are surviving cardiac arrest, focus needs to shift towards improving neurological outcomes and quality of life in survivors. Brain injury after resuscitation, a common sequela following cardiac arrest, ranges in severity from mild impairment to devastating brain injury and brainstem death. Effective strategies to minimise brain injury after resuscitation include early intervention with cardiopulmonary resuscitation and defibrillation, restoration of normal physiology, and targeted temperature management. It is important to identify people who might have a poor outcome, to enable informed choices about continuation or withdrawal of life-sustaining treatments. Multimodal prediction guidelines seek to avoid premature withdrawal in those who might survive with a good neurological outcome, or prolonging treatment that might result in survival with severe disability. Approximately one in three admitted to intensive care will survive, many of whom will need intensive, tailored rehabilitation after discharge to have the best outcomes.
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Affiliation(s)
- Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, University Hospitals Birmingham, Birmingham, UK.
| | - Clifton W Callaway
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Robert W Neumar
- Department of Emergency Medicine, Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Gisela Lilja
- Neurology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Matthew J Rowland
- Kadoorie Centre for Critical Care Research, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kelly N Sawyer
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
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28
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Du T, Mestre H, Kress BT, Liu G, Sweeney AM, Samson AJ, Rasmussen MK, Mortensen KN, Bork PAR, Peng W, Olveda GE, Bashford L, Toro ER, Tithof J, Kelley DH, Thomas JH, Hjorth PG, Martens EA, Mehta RI, Hirase H, Mori Y, Nedergaard M. Cerebrospinal fluid is a significant fluid source for anoxic cerebral oedema. Brain 2021; 145:787-797. [PMID: 34581781 DOI: 10.1093/brain/awab293] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 03/25/2021] [Accepted: 07/20/2021] [Indexed: 11/13/2022] Open
Abstract
Cerebral edema develops after anoxic brain injury. In two models of asphyxial and asystolic cardiac arrest without resuscitation, we found that edema develops shortly after anoxia secondary to terminal depolarizations and the abnormal entry of cerebrospinal fluid (CSF). Edema severity correlated with the availability of CSF with the age-dependent increase in CSF volume worsening the severity of edema. Edema was identified primarily in brain regions bordering CSF compartments in mice and humans. The degree of ex vivo tissue swelling was predicted by an osmotic model suggesting that anoxic brain tissue possesses a high intrinsic osmotic potential. This osmotic process was temperature-dependent, proposing an additional mechanism for the beneficial effect of therapeutic hypothermia. These observations show that CSF is a primary source of edema fluid in anoxic brain. This novel insight offers a mechanistic basis for the future development of alternative strategies to prevent cerebral edema formation after cardiac arrest.
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Affiliation(s)
- Ting Du
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Humberto Mestre
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA.,Department of Neuroscience, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Benjamin T Kress
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA.,Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Guojun Liu
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Amanda M Sweeney
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Andrew J Samson
- Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Martin Kaag Rasmussen
- Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Kristian Nygaard Mortensen
- Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Peter A R Bork
- Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark.,Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads, 2800 Kgs. Lyngby, Denmark
| | - Weiguo Peng
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA.,Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Genaro E Olveda
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Logan Bashford
- Department of Mechanical Engineering, University of Rochester, Rochester, NY 14627, USA
| | - Edna R Toro
- Department of Mechanical Engineering, University of Rochester, Rochester, NY 14627, USA
| | - Jeffrey Tithof
- Department of Mechanical Engineering, University of Rochester, Rochester, NY 14627, USA
| | - Douglas H Kelley
- Department of Mechanical Engineering, University of Rochester, Rochester, NY 14627, USA
| | - John H Thomas
- Department of Mechanical Engineering, University of Rochester, Rochester, NY 14627, USA
| | - Poul G Hjorth
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads, 2800 Kgs. Lyngby, Denmark
| | - Erik A Martens
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads, 2800 Kgs. Lyngby, Denmark
| | - Rupal I Mehta
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA.,Rush University Alzheimer's Disease Center, Department of Pathology, Rush University, Chicago, IL, USA
| | - Hajime Hirase
- Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Yuki Mori
- Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Maiken Nedergaard
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14642, USA.,Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark
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29
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Abstract
The susceptibility of the brain to ischaemic injury dramatically limits its viability following interruptions in blood flow. However, data from studies of dissociated cells, tissue specimens, isolated organs and whole bodies have brought into question the temporal limits within which the brain is capable of tolerating prolonged circulatory arrest. This Review assesses cell type-specific mechanisms of global cerebral ischaemia, and examines the circumstances in which the brain exhibits heightened resilience to injury. We suggest strategies for expanding such discoveries to fuel translational research into novel cytoprotective therapies, and describe emerging technologies and experimental concepts. By doing so, we propose a new multimodal framework to investigate brain resuscitation following extended periods of circulatory arrest.
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30
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Wiklund L, Sharma A, Patnaik R, Muresanu DF, Sahib S, Tian ZR, Castellani RJ, Nozari A, Lafuente JV, Sharma HS. Upregulation of hemeoxygenase enzymes HO-1 and HO-2 following ischemia-reperfusion injury in connection with experimental cardiac arrest and cardiopulmonary resuscitation: Neuroprotective effects of methylene blue. PROGRESS IN BRAIN RESEARCH 2021; 265:317-375. [PMID: 34560924 DOI: 10.1016/bs.pbr.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Oxidative stress plays an important role in neuronal injuries after cardiac arrest. Increased production of carbon monoxide (CO) by the enzyme hemeoxygenase (HO) in the brain is induced by the oxidative stress. HO is present in the CNS in two isoforms, namely the inducible HO-1 and the constitutive HO-2. Elevated levels of serum HO-1 occurs in cardiac arrest patients and upregulation of HO-1 in cardiac arrest is seen in the neurons. However, the role of HO-2 in cardiac arrest is not well known. In this review involvement of HO-1 and HO-2 enzymes in the porcine brain following cardiac arrest and resuscitation is discussed based on our own observations. In addition, neuroprotective role of methylene blue- an antioxidant dye on alterations in HO under in cardiac arrest is also presented. The biochemical findings of HO-1 and HO-2 enzymes using ELISA were further confirmed by immunocytochemical approach to localize selective regional alterations in cardiac arrest. Our observations are the first to show that cardiac arrest followed by successful cardiopulmonary resuscitation results in significant alteration in cerebral concentrations of HO-1 and HO-2 levels indicating a prominent role of CO in brain pathology and methylene blue during CPR followed by induced hypothermia leading to superior neuroprotection after return of spontaneous circulation (ROSC), not reported earlier.
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Affiliation(s)
- Lars Wiklund
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
| | - Ranjana Patnaik
- Department of Biomaterials, School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, India
| | - Dafin F Muresanu
- Department of Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania; "RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Seaab Sahib
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Z Ryan Tian
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Rudy J Castellani
- Department of Pathology, University of Maryland, Baltimore, MD, United States
| | - Ala Nozari
- Anesthesiology & Intensive Care, Massachusetts General Hospital, Boston, MA, United States
| | - José Vicente Lafuente
- LaNCE, Department of Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Bizkaia, Spain
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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31
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The Association Between Neurological Prognosis and the Degree of Blood-Brain Barrier Disruption in Cardiac Arrest Survivors Who Underwent Target Temperature Management. Neurocrit Care 2021; 35:815-824. [PMID: 34136993 DOI: 10.1007/s12028-021-01241-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study aimed to compare day-specific associations of blood-brain barrier (BBB) disruption with neurological outcome in survivors of out-of-hospital cardiac arrest (OHCA) treated with target temperature management (TTM) and lumbar drainage. METHODS This retrospective single-center study included 68 survivors of OHCA who underwent TTM between April 2018 and December 2019. The albumin quotient (QA) was calculated as QA = albumincerebrospinal fluid/albuminserum immediately (day 1) and 24 (day 2), 48 (day 3), and 72 h (day 4) after the return of spontaneous circulation. The degree of BBB disruption was weighted using the following scoring system: QA value of 0.007 or less (normal), QA value greater than 0.007-0.01 (mild), QA value greater than 0.01-0.02 (moderate), and QA value greater than 0.02 (severe). Points were assigned as follows: 0 (normal), 1 (mild), 4 (moderate), and 9 (severe). Neurological outcome was determined at 6 months after the return of spontaneous circulation, as well as cerebral performance category (CPC), dichotomized as good (CPC score 1-2) and poor (CPC score 3-5) outcome. RESULTS We enrolled 68 patients (48 men, 71%); 37 (54%) patients had a poor neurological outcome. The distributions of poor versus good outcomes at 6 months in patients with moderate and severe BBB disruption were 19 of 22 (80%) vs. 18 of 46 (50%) on day 1, 31 of 37 (79%) vs. 6 of 31 (32%) on day 2, 32 of 37 (81%) vs. 5 of 31 (30%) on day 3, and 32 of 39 (85%) vs. 5 of 29 (30%) on day 4 (P < 0.001), respectively. Using receiver operating characteristic analyses, optimal cutoff values (sensitivity, specificity) of QA levels for the prediction of neurological outcome were as follows: day 1, greater than 0.009 (56.8%, 87.1%); day 2, greater than 0.012 (81.1%, 87.1%); day 3, greater than 0.013 (83.8%, 87.1%); day 4, greater than 0.013 (86.5%, 87.1%); the sum of all time points, greater than 0.039 (89.5%, 79.4%); and scoring system, greater than 9 (91.9%, 87.1%). CONCLUSIONS In this proof of concept study, QA was associated with poor neurological outcome in survivors of OHCA treated with TTM with no contraindication to lumbar drainage. A large multicenter prospective study is needed to validate the utility of BBB disruption as a prognosticator of neurological outcome.
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32
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Hansen FB, Secher N, Mattson T, Løfgren B, Simonsen U, Granfeldt A. Effect of the KCa3.1 blocker, senicapoc, on cerebral edema and cardiovascular function after cardiac arrest - A randomized experimental rat study. Resusc Plus 2021; 6:100111. [PMID: 34223371 PMCID: PMC8244250 DOI: 10.1016/j.resplu.2021.100111] [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: 12/30/2020] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 11/30/2022] Open
Abstract
Senicapoc was successfully administered intravenously. Senicapoc did not reduce cerebral edema 4 h after cardiac arrest. Senicapoc did not increase mean arterial pressure within 4 h from resuscitation.
Aim Formation of cerebral edema and cardiovascular dysfunction may worsen brain injury following cardiac arrest. We hypothesized that administration of the intermediate calcium-activated potassium (KCa3.1) channel blocker, senicapoc, would reduce cerebral edema and augment mean arterial pressure in the early post-resuscitation period. Method Male Sprague-Dawley rats, aged 11–15 weeks, were utilized in the study. Rats were exposed to 8 min of asphyxial cardiac arrest. Shortly after resuscitation, rats were randomized to receive either vehicle or senicapoc (10 mg/kg) intravenously. The primary outcome was cerebral wet to dry weight ratio 4 h after resuscitation. Secondary outcomes included mean arterial pressure, cardiac output, norepinephrine dose, inflammatory cytokines and neuron specific enolase levels. Additionally, a sub-study was conducted to validate intravenous administration of senicapoc. Results The sub-study revealed that senicapoc-treated rats maintained a significantly higher mean arterial pressure during administration of SKA-31 (a KCa3.1 channel opener). The plasma concentration of senicapoc was 1060 ± 303 ng/ml 4 h after administration. Senicapoc did not reduce cerebral edema or augment mean arterial pressure 4 h after resuscitation. Likewise, cardiac function and norepinephrine dose did not vary between groups. Inflammatory cytokines and neuron specific enolase levels increased in both groups after resuscitation with no difference between groups. Senicapoc enhanced the PaO2/FiO2 ratio significantly 4 h after resuscitation. Conclusion Senicapoc was successfully administered intravenously after resuscitation, but did not reduce cerebral edema or increase mean arterial pressure in the early post-resuscitation period.
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Affiliation(s)
- Frederik Boe Hansen
- Department of Biomedicine, Aarhus University, Ole Worms Allé 4, 8000 Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus N, Denmark
| | - Niels Secher
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Thomas Mattson
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Bo Løfgren
- Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers NE, Denmark.,Research Center for Emergency Medicine, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200 Aarhus N, Denmark
| | - Ulf Simonsen
- Department of Biomedicine, Aarhus University, Ole Worms Allé 4, 8000 Aarhus, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus N, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
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33
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Neuromonitoring After Cardiac Arrest: Can Twenty-First Century Medicine Personalize Post Cardiac Arrest Care? Neurol Clin 2021; 39:273-292. [PMID: 33896519 DOI: 10.1016/j.ncl.2021.01.002] [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: 11/20/2022]
Abstract
Cardiac arrest survivors comprise a heterogeneous population, in which the etiology of arrest, systemic and neurologic comorbidities, and sequelae of post-cardiac arrest syndrome influence the severity of secondary brain injury. The degree of secondary neurologic injury can be modifiable and is influenced by factors that alter cerebral physiology. Neuromonitoring techniques provide tools for evaluating the evolution of physiologic variables over time. This article reviews the pathophysiology of hypoxic-ischemic brain injury, provides an overview of the neuromonitoring tools available to identify risk profiles for secondary brain injury, and highlights the importance of an individualized approach to post cardiac arrest care.
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34
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Fuller ZL, Faro JW, Callaway CW, Coppler PJ, Elmer J. Recovery among post-arrest patients with mild-to-moderate cerebral edema. Resuscitation 2021; 162:149-153. [PMID: 33662524 DOI: 10.1016/j.resuscitation.2021.02.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cerebral edema after cardiac arrest may be a modifiable cause of secondary brain injury. We aimed to identify processes of care associated with recovery in a cohort of patients with mild to moderate edema. METHODS We conducted a retrospective cohort study of adults resuscitated from out-of-hospital arrest (OHCA) at a single center from 2010 to 2018. We included those with cerebral edema ranging from mild to moderate (gray to white matter attenuation ratio (GWR) 1.2 to 1.3 on initial brain computerized tomography (CT). We used Pittsburgh Cardiac Arrest Category (PCAC) to adjust for illness severity and considered the following values in the first 24 h of admission as additional predictors: GWR, lab values affecting serum osmolality (sodium, glucose, blood urea nitrogen (BUN)), total osmolality, change in osmolality from 0 to 24 h, cardiac etiology of arrest, targeted temperature to 33 °C (vs 36 °C), time-weighted mean arterial pressure (MAP), partial pressures of arterial oxygen and carbon dioxide and select medications. Our primary outcome was discharge with cerebral performance category 1-3. We used unadjusted and adjusted logistic regression for analysis. RESULTS We included 214 patients for whom CT was performed median 3.8 [IQR 2.4-5.2] hours after collapse. Median age was 57 [IQR 48-67] years, 82 (38%) were female, and 68 (32%) arrested from ventricular tachycardia or fibrillation. In adjusted models, modifiable processes of care were not associated with outcome. CONCLUSIONS Illness severity, but not modifiable processes of care, were associated with recovery among post-arrest patients with mild-to-moderate cerebral edema.
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Affiliation(s)
- Zachary L Fuller
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John W Faro
- University of Cincinnati, Cincinnati College of Medicine, OH, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
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35
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Son SH, In YN, Md, Park JS, You Y, Min JH, Yoo I, Cho YC, Jeong W, Ahn HJ, Kang C, Lee BK. Cerebrospinal Fluid Lactate Levels, Brain Lactate Metabolism and Neurologic Outcome in Patients with Out-of-Hospital Cardiac Arrest. Neurocrit Care 2021; 35:262-270. [PMID: 33432527 DOI: 10.1007/s12028-020-01181-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/15/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND/OBJECTIVE Cerebrospinal fluid (CSF) and serum lactate levels were assessed to predict poor neurologic outcome 3 months after return of spontaneous circulation (ROSC). We compared arterio-CSF differences in the lactate (ACDL) levels between two neurologic outcome groups. METHODS This retrospective observational study involved out-of-hospital cardiac arrest (OHCA) survivors who had undergone target temperature management. CSF and serum samples were obtained immediately (lactate0), and at 24 (lactate24), 48 (lactate48), and 72 (lactate72) h after ROSC, and ACDL was calculated at each time point. The primary outcome was poor 3-month neurologic outcome (cerebral performance categories 3-5). RESULTS Of 45 patients, 27 (60.0%) showed poor neurologic outcome. At each time point, CSF lactate levels were significantly higher in the poor neurologic outcome group than in the good neurologic outcome group (6.97 vs. 3.37, 4.20 vs. 2.10, 3.50 vs. 2.00, and 2.79 vs. 2.06, respectively; all P < 0.05). CSF lactate's prognostic performance was higher than serum lactate at each time point, and lactate24 showed the highest AUC values (0.89, 95% confidence interval, 0.75-0.97). Over time, ACDL decreased from - 1.30 (- 2.70-0.77) to - 1.70 (- 3.2 to - 0.57) in the poor neurologic outcome group and increased from - 1.22 (- 2.42-0.32) to - 0.64 (- 2.31-0.15) in the good neurologic outcome group. CONCLUSIONS At each time point, CSF lactate showed better prognostic performance than serum lactate. CSF lactate24 showed the highest prognostic performance for 3-month poor neurologic outcome. Over time, ACDL decreased in the poor neurologic outcome group and increased in the good neurologic outcome group.
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Affiliation(s)
- Seung Ha Son
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | | | - Md
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea. .,Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea.
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Insool Yoo
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Chungnam National University, 282, Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, 61469, Korea
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The Usefulness of Quantitative Analysis of Blood-Brain Barrier Disruption Measured Using Contrast-Enhanced Magnetic Resonance Imaging to Predict Neurological Prognosis in Out-of-Hospital Cardiac Arrest Survivors: A Preliminary Study. J Clin Med 2020; 9:jcm9093013. [PMID: 32962022 PMCID: PMC7564654 DOI: 10.3390/jcm9093013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 12/14/2022] Open
Abstract
We aimed to evaluate neurological outcomes associated with blood-brain barrier (BBB) disruption using contrast-enhanced magnetic resonance imaging (CE-MRI) in out-of-hospital cardiac arrest (OHCA) survivors. This retrospective observational study involved OHCA survivors who had undergone CE-MRI for prognostication. Qualitative and quantitative analyses were performed using the presence of BBB disruption (pBD) and the BBB disruption score (sBD) in CE-MRI scans, respectively. For the sBD, 1 point was assigned for each area of BBB disruption, and 6 points were assigned when an absence of intracranial blood flow due to severe brain oedema was confirmed. The primary outcome was poor neurological outcome at 3 months (defined as cerebral performance categories 3-5). We analysed 46 CE-MRI brain scans (27 patients). Of these, 15 (55.6%) patients had poor neurological outcomes. Poor neurological outcome group patients showed a significantly higher proportion of pBD than those in the good neurological outcome group (22 (88%) vs. 6 (28.6%) patients, respectively, p < 0.001) and a higher sBD (5.0 (4.0-5.0) vs. 0.0 (0.0-1.0) patients, p < 0.001). Poor neurological outcome predictions showed that the sBD had a significantly better prognostic performance (area under the curve (AUC) 0.95, 95% confidence interval (CI) 0.84-0.99) than the pBD (AUC 0.80, 95% CI 0.65-0.90). The sBD cut-off value was >1 point (sensitivity, 96.0%; specificity, 81.0%). The sBD is a highly predictive and sensitive marker of 3-month poor neurological outcome in OHCA survivors. Multicentre prospective studies are required to determine the generalisability of these results.
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Boller M, Fletcher DJ. Update on Cardiopulmonary Resuscitation in Small Animals. Vet Clin North Am Small Anim Pract 2020; 50:1183-1202. [PMID: 32798056 DOI: 10.1016/j.cvsm.2020.06.010] [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: 11/28/2022]
Abstract
Cardiopulmonary arrest (CPA), the acute cessation of ventilation and systemic perfusion, leads to discontinuation of tissue oxygen delivery and death if not quickly reversed. Reported resuscitation rates suggest that the heart can be restarted in 40% to 50% of dogs and cats treated with cardiopulmonary resuscitation (CPR). However, approximately 80% of these animals do not survive to hospital discharge. To minimize mortality due to CPA a broad strategy is required including preparedness and prevention measures, basic and advanced life support as well as post-cardiac arrest care. This article summarizes the current guidelines on the treatment of small animals with CPA..
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Affiliation(s)
- Manuel Boller
- Melbourne Veterinary School, The University of Melbourne, Melbourne, Victoria, Australia.
| | - Daniel J Fletcher
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, DCS Box 31, Ithaca, NY 14853, USA
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Abstract
Background Abnormal restricted diffusion on magnetic resonance imaging is often associated with ischemic stroke or anoxic injury, but other conditions can present similarly. We present six cases of an unusual but consistent pattern of restricted diffusion in bilateral hippocampi and cerebellar cortices. This pattern of injury is distinct from typical imaging findings in ischemic, anoxic, or toxic injury, suggesting it may represent an under-recognized clinicoradiographic syndrome. Despite initial presentation with stupor or coma in the context of obstructive hydrocephalus, patients may have acceptable outcomes if offered early intervention. Methods We identified an ad hoc series of patients at our two institutions between years 2014 and 2017 who presented to the neurocritical care unit with severe, otherwise unexplained cerebellar edema and retrospectively identified several commonalities in history, presentation, and imaging. Results Between two institutions, we identified six patients—ages 33–59 years, four male—with similar presentations of decreased level of consciousness in the context of intoxicant exposure, with acute cytotoxic edema of the cerebellar cortex, hippocampi, and aspects of the basal nuclei. All patients presented with severe cerebellar edema which led to obstructive hydrocephalus requiring aggressive medical and/or surgical management. The five patients who survived to discharge demonstrated variable degrees of physical and memory impairment on discharge and at follow-up. Conclusions We present findings of a potentially novel syndrome involving a distinct pattern of cerebellar and hippocampal restricted diffusion, with imaging and clinical characteristics distinct from ischemic stroke, hypoxic injury, and known toxidromes and leukoencephalopathies. Given the potential for favorable outcome despite early obstructive hydrocephalus, early identification and treatment of this syndrome are critical.
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Rud J, May TL, Riker RR, Seder DB. Early cerebral edema after cardiac arrest and its ramifications. Resuscitation 2020; 154:112-114. [PMID: 32619533 DOI: 10.1016/j.resuscitation.2020.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Jonathan Rud
- Maine Medical Center Department of Internal Medicine, Portland, ME, USA
| | - Teresa L May
- Maine Medical Center Department of Critical Care Services, Portland, ME, USA; Tufts University School of Medicine, Boston, MA, USA
| | - Richard R Riker
- Maine Medical Center Department of Critical Care Services, Portland, ME, USA; Tufts University School of Medicine, Boston, MA, USA
| | - David B Seder
- Maine Medical Center Department of Critical Care Services, Portland, ME, USA; Tufts University School of Medicine, Boston, MA, USA.
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Esdaille CJ, Coppler PJ, Faro JW, Weisner ZM, Condle JP, Elmer J, Callaway CW. Duration and clinical features of cardiac arrest predict early severe cerebral edema. Resuscitation 2020; 153:111-118. [PMID: 32590271 DOI: 10.1016/j.resuscitation.2020.05.049] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 05/22/2020] [Accepted: 05/31/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Severe brain edema appears early after cardiopulmonary resuscitation (CPR) in a subset of patients and portends a poor prognosis. We tested whether clinical features of patients or resuscitation during out-of-hospital cardiac arrest (OHCA) are associated with early, severe cerebral edema. METHOD/RESEARCH DESIGN We reviewed pre-hospital and hospital records for comatose patients surviving to hospital admission after OHCA who had computed tomography (CT) of brain at the time of hospital admission available for inspection. We measured the gray-white ratio (GWR) of X-ray attenuation between the caudate nucleus and posterior limb of the internal capsule, defining severe cerebral edema as GWR < 1.20. We calculated associations between severe cerebral edema and patient or resuscitation variables. RESULTS Between 2010 and 2019, 1340 subjects were admitted of whom 296 (22%) showed severe cerebral edema on initial CT. Subjects with severe edema had lower survival (5/296, 2% vs. 377/1044, 36%). Severe edema was independently associated with total CPR duration, total dose of epinephrine, younger age, non-shockable arrest rhythms, fewer total number of rescue shocks, rearrest after initial return of pulses, and non-cardiac arrest etiology. Prevalence of severe cerebral edema increased from 2% among subjects with 0-10 min of CPR to 31% among subjects with >40 min of CPR. CONCLUSION CPR duration along with easily measurable clinical and resuscitation characteristics predict early severe cerebral edema after OHCA. Future interventional trials should consider targeting or preventing cerebral edema after prolonged hypoxic-ischemic brain injury especially in patients with high risk clinical features.
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Affiliation(s)
- C Jayson Esdaille
- Howard University College of Medicine, Washington, DC, United States
| | - Patrick J Coppler
- Pittsburgh Post Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - John W Faro
- University of Cincinnati, Cincinnati, OH, United States
| | | | - Joseph P Condle
- Pittsburgh Post Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jonathan Elmer
- Pittsburgh Post Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Clifton W Callaway
- Pittsburgh Post Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
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Is jugular bulb oximetry monitoring associated with outcome in out of hospital cardiac arrest patients? J Clin Monit Comput 2020; 35:741-748. [PMID: 32435933 PMCID: PMC8286927 DOI: 10.1007/s10877-020-00530-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 05/13/2020] [Indexed: 01/31/2023]
Abstract
Cerebral protection against secondary hypoxic-ischemic brain injury is a key priority area in post-resuscitation intensive care management in survivors of cardiac arrest. Nevertheless, the current understanding of the incidence, diagnosis and its’ impact on neurological outcome remains undetermined. The aim of this study was to evaluate jugular bulb oximetry as a potential monitoring modality to detect the incidences of desaturation episodes during post-cardiac arrest intensive care management and to evaluate their subsequent impact on neurological outcome. We conducted a prospective, observational study in unconscious adult patients admitted to the intensive care unit who had successful resuscitation following out of hospital cardiac arrest of presumed cardiac causes. All the patients were treated as per European Resuscitation Council 2015 guidelines and they received jugular bulb catheter. Jugular bulb oximetry measurements were performed at six hourly intervals. The neurological outcomes were evaluated on 90th day after the cardiac arrest by cerebral performance categories scale. Forty patients met the eligibility criteria. Measurements of jugular venous oxygen saturation were performed for 438 times. Altogether, we found 2 incidences of jugular bulb oxygen saturation less than 50% (2/438; 0.46%), and 4 incidences when it was less than 55% (4/438; 0.91%). The study detected an association between SjVO2 and CO2 (r = 0.26), each 1 kPa increase in CO2 led to an increase in SjvO2 by 3.4% + / − 0.67 (p < 0.0001). There was no association between SjvO2 and PaO2 or SjvO2 and MAP. We observed a statistically significant higher mean SjvO2 (8.82% + / − 2.05, p < 0.0001) in unfavorable outcome group. The episodes of brain hypoxia detected by jugular bulb oxygen saturation were rare during post-resuscitation intensive care management in out of hospital cardiac arrest patients. Therefore, this modality of monitoring may not yield any additional information towards prevention of secondary hypoxic ischemic brain injury in post cardiac arrest survivors. Other factors contributing towards high jugular venous saturation needs to be considered.
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Hosseini M, Wilson RH, Crouzet C, Amirhekmat A, Wei KS, Akbari Y. Resuscitating the Globally Ischemic Brain: TTM and Beyond. Neurotherapeutics 2020; 17:539-562. [PMID: 32367476 PMCID: PMC7283450 DOI: 10.1007/s13311-020-00856-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cardiac arrest (CA) afflicts ~ 550,000 people each year in the USA. A small fraction of CA sufferers survive with a majority of these survivors emerging in a comatose state. Many CA survivors suffer devastating global brain injury with some remaining indefinitely in a comatose state. The pathogenesis of global brain injury secondary to CA is complex. Mechanisms of CA-induced brain injury include ischemia, hypoxia, cytotoxicity, inflammation, and ultimately, irreversible neuronal damage. Due to this complexity, it is critical for clinicians to have access as early as possible to quantitative metrics for diagnosing injury severity, accurately predicting outcome, and informing patient care. Current recommendations involve using multiple modalities including clinical exam, electrophysiology, brain imaging, and molecular biomarkers. This multi-faceted approach is designed to improve prognostication to avoid "self-fulfilling" prophecy and early withdrawal of life-sustaining treatments. Incorporation of emerging dynamic monitoring tools such as diffuse optical technologies may provide improved diagnosis and early prognostication to better inform treatment. Currently, targeted temperature management (TTM) is the leading treatment, with the number of patients needed to treat being ~ 6 in order to improve outcome for one patient. Future avenues of treatment, which may potentially be combined with TTM, include pharmacotherapy, perfusion/oxygenation targets, and pre/postconditioning. In this review, we provide a bench to bedside approach to delineate the pathophysiology, prognostication methods, current targeted therapies, and future directions of research surrounding hypoxic-ischemic brain injury (HIBI) secondary to CA.
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Affiliation(s)
- Melika Hosseini
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Robert H Wilson
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Christian Crouzet
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Arya Amirhekmat
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Kevin S Wei
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Yama Akbari
- Department of Neurology, School of Medicine, University of California, Irvine, USA.
- Beckman Laser Institute, University of California, Irvine, USA.
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Park JS, You Y, Ahn HJ, Min JH, Jeong W, Yoo I, Cho Y, Ryu S, Lee J, Kim S, Cho SU, Oh SK, Kang CS, Lee BK. Cerebrospinal fluid lactate dehydrogenase as a potential predictor of neurologic outcomes in cardiac arrest survivors who underwent target temperature management. J Crit Care 2020; 57:49-54. [PMID: 32062287 DOI: 10.1016/j.jcrc.2020.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Cerebrospinal fluid (CSF) lactate dehydrogenase (LDH) levels increase in patients with brain injury. We investigated neurologic outcomes associated with CSF LDH levels in out-of-hospital cardiac arrest (OHCA) survivors who underwent target temperature management (TTM). MATERIALS AND METHODS This was a prospective single-centre observational study from April 2018 to May 2019 on a cohort of 41 patients. CSF and serum LDH samples were obtained immediately (LDH0) and at 24 (LDH24), 48 (LDH48), and 72 h (LDH72) after return of spontaneous circulation (ROSC). Neurologic outcomes were assessed at 3 months after ROSC using the Cerebral Performance Category scale. RESULTS Twenty-one patients had a poor neurologic outcome. CSF LDH levels were significantly higher in the poor neurologic outcome group at each time point. The area under the curve (AUC) of CSF LDH48 was 0.941 (95% confidence interval [CI], 0.806-0.992). With a cut off value of 250 U/L, CSF LDH48 had a high sensitivity (94.1%; 95% CI, 71.3-99.9) at 100% specificity. CONCLUSIONS CSF LDH level at 48 h was a highly specific and sensitive marker for 3-month poor neurologic outcome. This may constitute a useful predictive marker for neurologic outcome in OHCA survivors treated with TTM.
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Affiliation(s)
- 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
| | - Yeonho You
- 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.
| | - Jin Hong Min
- 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
| | - Insool Yoo
- 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
| | - Seung Ryu
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jinwoong Lee
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Seungwhan Kim
- 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
| | - Sung Uk Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Se Kwang Oh
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Chang Shin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University School of Medicine, Gwangju, Republic of Korea
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Son SH, Park JS, Yoo IS, You YH, Min JH, Jeong WJ, Cho YC, Cho SU, Oh SK, Ahn HJ, Song HG, Lee BK, Lee DH, Youn CS, Oh E. Usefulness of Intracranial Pressure and Mean Arterial Pressure for Predicting Neurological Prognosis in Cardiac Arrest Survivors Who Undergo Target Temperature Management. Ther Hypothermia Temp Manag 2019; 10:165-170. [PMID: 31526251 DOI: 10.1089/ther.2019.0006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We aimed to compare the relationship of mean arterial pressure (MAP) and intracranial pressure (ICP) to predict the neurological prognosis in cardiac arrest (CA) survivors. We retrospectively examined out-of-hospital CA patients treated with targeted temperature management. ICP was measured using cerebrospinal fluid (CSF) pressure, whereas MAP was measured as blood pressure monitored through the radial or femoral artery during CSF pressure measurement. Primary outcome was 6-month neurological outcome. Of 92 enrolled patients, the favorable outcome group comprised 31 (34%) patients. The median and interquartile range of MAP were significantly higher and ICP was significantly lower in patients with favorable neurological outcomes than in those with unfavorable neurological outcomes (94.3 mmHg [80.0-105.3] vs. 82.0 mmHg [65.3-96.3], p = 0.021 and 9.4 mmHg [10.8-8.7] vs. 18.8 mmHg [20.0-15.7], p < 0.001, respectively). ICP showed the higher area under the receiver operating characteristic curve (area under curve [AUC] = 0.953, 95% confidence interval [CI] = 0.888-0.986) for neurological outcome prediction. MAP showed the lower AUC (0.648, 95% CI = 0.541-0.744). Higher accurate prognosis was predicted by ICP than MAP, and the prognostic performance was good. Prospective multicenter studies are required to confirm these results.
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Affiliation(s)
- Seung Ha Son
- 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.,Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - In Sool Yoo
- 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
| | - Yeon Ho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Won Joon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Sung Uk Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Se Kwang Oh
- 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
| | - Ho Gul Song
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Chun Song Youn
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Eungseok Oh
- Department of Neurology, Chungnam National University Hospital, Daejeon, Republic of Korea
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Usefulness of a quantitative analysis of the cerebrospinal fluid volume proportion in brain computed tomography for predicting neurological prognosis in cardiac arrest survivors who undergo target temperature management. J Crit Care 2019; 51:170-174. [DOI: 10.1016/j.jcrc.2019.02.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/22/2018] [Accepted: 02/20/2019] [Indexed: 11/22/2022]
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Robba C, Goffi A, Geeraerts T, Cardim D, Via G, Czosnyka M, Park S, Sarwal A, Padayachy L, Rasulo F, Citerio G. Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review. Intensive Care Med 2019; 45:913-927. [PMID: 31025061 DOI: 10.1007/s00134-019-05610-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/26/2019] [Indexed: 12/20/2022]
Abstract
Brain ultrasonography can be used to evaluate cerebral anatomy and pathology, as well as cerebral circulation through analysis of blood flow velocities. Transcranial colour-coded duplex sonography is a generally safe, repeatable, non-invasive, bedside technique that has a strong potential in neurocritical care patients in many clinical scenarios, including traumatic brain injury, aneurysmal subarachnoid haemorrhage, hydrocephalus, and the diagnosis of cerebral circulatory arrest. Furthermore, the clinical applications of this technique may extend to different settings, including the general intensive care unit and the emergency department. Its increasing use reflects a growing interest in non-invasive cerebral and systemic assessment. The aim of this manuscript is to provide an overview of the basic and advanced principles underlying brain ultrasonography, and to review the different techniques and different clinical applications of this approach in the monitoring and treatment of critically ill patients.
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Affiliation(s)
- Chiara Robba
- Department of Anaesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Geeraerts
- Department of Anaesthesia and Intensive Care, University Hospital of Toulouse, Toulouse NeuroImaging Center (ToNIC), Inserm-UPS, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Soojin Park
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University, New York, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Llewellyn Padayachy
- Department of Neurosurgery, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Frank Rasulo
- Department of Anaesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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You Y, Park J, Min J, Yoo I, Jeong W, Cho Y, Ryu S, Lee J, Kim S, Cho S, Oh S, Lee J, Ahn H, Lee B, Lee D, Na K, In Y, Kwack C, Lee J. Relationship between time related serum albumin concentration, optic nerve sheath diameter, cerebrospinal fluid pressure, and neurological prognosis in cardiac arrest survivors. Resuscitation 2018; 131:42-47. [DOI: 10.1016/j.resuscitation.2018.08.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/30/2018] [Accepted: 08/03/2018] [Indexed: 01/03/2023]
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48
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Comments on the Cerebral Edema After CPR: A Therapeutic Target Following Cardiac Arrest? Neurocrit Care 2018; 28:260. [DOI: 10.1007/s12028-018-0510-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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49
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Hayman E, Simard JM. Reply to “Comments on the Cerebral Edema After CPR: A Therapeutic Target Following Cardiac Arrest?”. Neurocrit Care 2018; 28:261. [DOI: 10.1007/s12028-018-0511-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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