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Rass V, Ianosi BA, Lindner A, Kindl P, Schiefecker AJ, Helbok R, Pfausler B, Beer R. Beyond Control: Temperature Burden in Patients with Spontaneous Subarachnoid Hemorrhage-An Observational Study. Neurocrit Care 2024:10.1007/s12028-024-02022-1. [PMID: 38902581 DOI: 10.1007/s12028-024-02022-1] [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: 02/08/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Temperature abnormalities are common after spontaneous subarachnoid hemorrhage (SAH). Here, we aimed to describe the evolution of temperature burden despite temperature control and to assess its impact on outcome parameters. METHODS This retrospective observational study of prospectively collected data included 375 consecutive patients with SAH admitted to the neurological intensive care unit between 2010 and 2022. Daily fever (defined as the area over the curve above 37.9 °C multiplied by hours with fever) and spontaneous hypothermia burden (< 36.0 °C) were calculated over the study period of 16 days. Generalized estimating equations were used to calculate risk factors for increased temperature burdens and the impact of temperature burden on outcome parameters after correction for predefined variables. RESULTS Patients had a median age of 58 years (interquartile range 49-68) and presented with a median Hunt & Hess score of 3 (interquartile range 2-5) on admission. Fever (temperature > 37.9 °C) was diagnosed in 283 of 375 (76%) patients during 14% of the monitored time. The average daily fever burden peaked between days 5 and 10 after admission. Higher Hunt & Hess score (p = 0.014), older age (p = 0.033), and pneumonia (p = 0.022) were independent factors associated with delayed fever burden between days 5 and 10. Increased fever burden was independently associated with poor 3-month functional outcome (modified Rankin Scale 3-6, p = 0.027), poor 12-month functional outcome (p = 0.020), and in-hospital mortality (p = 0.045), but not with the development of delayed cerebral ischemia (p = 0.660) or intensive care unit length of stay (p = 0.573). Spontaneous hypothermia was evident in the first three days in patients with a higher Hunt & Hess score (p < 0.001) and intraventricular hemorrhage (p = 0.047). Spontaneous hypothermia burden was not associated with poor 3-month outcome (p = 0.271). CONCLUSIONS Early hypothermia was followed by fever after SAH. Increased fever time burden was associated with poor functional outcome after SAH and could be considered for neuroprognostication.
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Affiliation(s)
- Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Bogdan-Andrei Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Philipp Kindl
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Alois J Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
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Cadena AJ, Rincon F. Hypothermia and temperature modulation for intracerebral hemorrhage (ICH): pathophysiology and translational applications. Front Neurosci 2024; 18:1289705. [PMID: 38440392 PMCID: PMC10910040 DOI: 10.3389/fnins.2024.1289705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 02/07/2024] [Indexed: 03/06/2024] Open
Abstract
Background Intracerebral hemorrhage (ICH) still poses a substantial challenge in clinical medicine because of the high morbidity and mortality rate that characterizes it. This review article expands into the complex pathophysiological processes underlying primary and secondary neuronal death following ICH. It explores the potential of therapeutic hypothermia as an intervention to mitigate these devastating effects. Methods A comprehensive literature review to gather relevant studies published between 2000 and 2023. Discussion Primary brain injury results from mechanical damage caused by the hematoma, leading to increased intracranial pressure and subsequent structural disruption. Secondary brain injury encompasses a cascade of events, including inflammation, oxidative stress, blood-brain barrier breakdown, cytotoxicity, and neuronal death. Initial surgical trials failed to demonstrate significant benefits, prompting a shift toward molecular mechanisms driving secondary brain injury as potential therapeutic targets. With promising preclinical outcomes, hypothermia has garnered attention, but clinical trials have yet to establish its definitive effectiveness. Localized hypothermia strategies are gaining interest due to their potential to minimize systemic complications and improve outcomes. Ongoing and forthcoming clinical trials seek to clarify the role of hypothermia in ICH management. Conclusion Therapeutic hypothermia offers a potential avenue for intervention by targeting the secondary injury mechanisms. The ongoing pursuit of optimized cooling protocols, localized cooling strategies, and rigorous clinical trials is crucial to unlocking the potential of hypothermia as a therapeutic tool for managing ICH and improving patient outcomes.
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Affiliation(s)
- Angel J. Cadena
- Department of Neurology, Columbia University, New York, NY, United States
| | - Fred Rincon
- Department of Neurology, Division of Neurocritical Care, Cooper University, Camden, NJ, United States
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Hergenroeder GW, Yokobori S, Choi HA, Schmitt K, Detry MA, Schmitt LH, McGlothlin A, Puccio AM, Jagid J, Kuroda Y, Nakamura Y, Suehiro E, Ahmad F, Viele K, Wilde EA, McCauley SR, Kitagawa RS, Temkin NR, Timmons SD, Diringer MN, Dash PK, Bullock R, Okonkwo DO, Berry DA, Kim DH. Hypothermia for Patients Requiring Evacuation of Subdural Hematoma: A Multicenter Randomized Clinical Trial. Neurocrit Care 2021; 36:560-572. [PMID: 34518968 PMCID: PMC8964656 DOI: 10.1007/s12028-021-01334-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/13/2021] [Indexed: 11/24/2022]
Abstract
Background Hypothermia is neuroprotective in some ischemia–reperfusion injuries. Ischemia–reperfusion injury may occur with traumatic subdural hematoma (SDH). This study aimed to determine whether early induction and maintenance of hypothermia in patients with acute SDH would lead to decreased ischemia–reperfusion injury and improve global neurologic outcome. Methods This international, multicenter randomized controlled trial enrolled adult patients with SDH requiring evacuation of hematoma within 6 h of injury. The intervention was controlled temperature management of hypothermia to 35 °C prior to dura opening followed by 33 °C for 48 h compared with normothermia (37 °C). Investigators randomly assigned patients at a 1:1 ratio between hypothermia and normothermia. Blinded evaluators assessed outcome using a 6-month Glasgow Outcome Scale Extended score. Investigators measured circulating glial fibrillary acidic protein and ubiquitin C-terminal hydrolase L1 levels. Results Independent statisticians performed an interim analysis of 31 patients to assess the predictive probability of success and the Data and Safety Monitoring Board recommended the early termination of the study because of futility. Thirty-two patients, 16 per arm, were analyzed. Favorable 6-month Glasgow Outcome Scale Extended outcomes were not statistically significantly different between hypothermia vs. normothermia groups (6 of 16, 38% vs. 4 of 16, 25%; odds ratio 1.8 [95% confidence interval 0.39 to ∞], p = .35). Plasma levels of glial fibrillary acidic protein (p = .036), but not ubiquitin C-terminal hydrolase L1 (p = .26), were lower in the patients with favorable outcome compared with those with unfavorable outcome, but differences were not identified by temperature group. Adverse events were similar between groups. Conclusions This trial of hypothermia after acute SDH evacuation was terminated because of a low predictive probability of meeting the study objectives. There was no statistically significant difference in functional outcome identified between temperature groups. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01334-w.
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Affiliation(s)
- Georgene W Hergenroeder
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA. .,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA.
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Huimahn Alex Choi
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Karl Schmitt
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Michelle A Detry
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Lisa H Schmitt
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Anna McGlothlin
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan Jagid
- Department of Neurological Surgery, Jackson Memorial Hospital, University of Miami, Miami, FL, USA
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Kagawa University Hospital, Kagawa Prefecture, Japan
| | - Yukihiko Nakamura
- Emergency and Critical Care Medicine, Kurume University Hospital, Fukuoka, Japan
| | - Eiichi Suehiro
- Department of Neurosurgery, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Faiz Ahmad
- Department of Neurological Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Kert Viele
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Elisabeth A Wilde
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Stephen R McCauley
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Ryan S Kitagawa
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Nancy R Temkin
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle, WA, USA
| | - Shelly D Timmons
- Department of Neurological Surgery, Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael N Diringer
- Departments of Neurology, Neurological Surgery, Anesthesiology, and Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Pramod K Dash
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Department of Neurobiology and Anatomy, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ross Bullock
- Department of Neurological Surgery, Jackson Memorial Hospital, University of Miami, Miami, FL, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Donald A Berry
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Dong H Kim
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
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