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Goh J, Eramanis LM, Milne M, Boller M. Brain magnetic resonance imaging and histopathology findings in a dog with global brain ischaemia following cardiopulmonary arrest. Aust Vet J 2022; 100:433-439. [PMID: 35656570 PMCID: PMC9546154 DOI: 10.1111/avj.13178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/27/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
Abstract
Background Global brain ischaemia following cardiopulmonary arrest is uncommonly reported in veterinary medicine yet neurologic injury after arrest is a known morbidity. Case report An 18‐week‐old male entire Cavalier King Charles Spaniel‐Poodle was referred following 3 days of neurologic abnormalities after cardiopulmonary arrest. After resuscitation, the animal had decerebrate rigidity, a stuporous mentation and intermittent episodes of vocalisation and apnoea. A brain magnetic resonance imaging (MRI) was undertaken 4 days after cardiopulmonary arrest, with standard sequences (T1‐weighted, T2‐weighted and fluid‐attenuated inversion recovery) as well as diffusion‐weighted imaging to better discern ischaemic injury and cytotoxic oedema for prognostic reasons. MRI findings were consistent with global brain ischaemia affecting the hippocampus, cerebellum and substantia nigra, the latter two not previously identified in canine cases of global brain ischaemia. The patient was euthanased on day eight post‐cardiopulmonary arrest due to a lack of neurological improvement and developing sepsis as a complication. Ante‐mortem identification of affected areas of the brain was confirmed on histological examination, with evidence of ischaemic injury seen in the cerebrum, hippocampus, cerebellum, basal nuclei and thalamus. Conclusion This report describes ante‐mortem MRI and postmortem findings in a dog with global brain ischaemia following cardiopulmonary arrest. A multimodal approach to neuroprognostication in patients recovering from cardiopulmonary arrest is recommended.
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Affiliation(s)
- J Goh
- U‐Vet Animal Hospital, University of Melbourne 250 Princes Highway Werribee Victoria 3030 Australia
| | - LM Eramanis
- Small Animal Specialist Hospital Level 1, 1 Richardson Place North Ryde New South Wales 2113 Australia
| | - M Milne
- VetCT 185‐187 High Street, Suite 11 Ground Floor Fremantle Western Australia 6160 Australia
| | - M Boller
- U‐Vet Animal Hospital, University of Melbourne 250 Princes Highway Werribee Victoria 3030 Australia
- Central Victoria Veterinary Hospital, VCA Canada 760 Roderick Street Victoria British Columbia V8X 2R3 Canada
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Helbok R, Rass V, Beghi E, Bodien YG, Citerio G, Giacino JT, Kondziella D, Mayer SA, Menon D, Sharshar T, Stevens RD, Ulmer H, Venkatasubba Rao CP, Vespa P, McNett M, Frontera J. The Curing Coma Campaign International Survey on Coma Epidemiology, Evaluation, and Therapy (COME TOGETHER). Neurocrit Care 2022; 37:47-59. [PMID: 35141860 PMCID: PMC9283177 DOI: 10.1007/s12028-021-01425-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022]
Abstract
Background Although coma is commonly encountered in critical care, worldwide variability exists in diagnosis and management practices. We aimed to assess variability in coma definitions, etiologies, treatment strategies, and attitudes toward prognosis. Methods As part of the Neurocritical Care Society Curing Coma Campaign, between September 2020 and January 2021, we conducted an anonymous, international, cross-sectional global survey of health care professionals caring for patients with coma and disorders of consciousness in the acute, subacute, or chronic setting. Survey responses were solicited by sequential emails distributed by international neuroscience societies and social media. Fleiss κ values were calculated to assess agreement among respondents. Results The survey was completed by 258 health care professionals from 41 countries. Respondents predominantly were physicians (n = 213, 83%), were from the United States (n = 141, 55%), and represented academic centers (n = 231, 90%). Among eight predefined items, respondents identified the following cardinal features, in various combinations, that must be present to define coma: absence of wakefulness (81%, κ = 0.764); Glasgow Coma Score (GCS) ≤ 8 (64%, κ = 0.588); failure to respond purposefully to visual, verbal, or tactile stimuli (60%, κ = 0.552); and inability to follow commands (58%, κ = 0.529). Reported etiologies of coma encountered included medically induced coma (24%), traumatic brain injury (24%), intracerebral hemorrhage (21%), and cardiac arrest/hypoxic-ischemic encephalopathy (11%). The most common clinical assessment tools used for coma included the GCS (94%) and neurological examination (78%). Sixty-six percent of respondents routinely performed sedation interruption, in the absence of contraindications, for clinical coma assessments in the intensive care unit. Advanced neurological assessment techniques in comatose patients included quantitative electroencephalography (EEG)/connectivity analysis (16%), functional magnetic resonance imaging (7%), single-photon emission computerized tomography (6%), positron emission tomography (4%), invasive EEG (4%), and cerebral microdialysis (4%). The most commonly used neurostimulants included amantadine (51%), modafinil (37%), and methylphenidate (28%). The leading determinants for prognostication included etiology of coma, neurological examination findings, and neuroimaging. Fewer than 20% of respondents reported routine follow-up of coma survivors after hospital discharge; however, 86% indicated interest in future research initiatives that include postdischarge outcomes at six (85%) and 12 months (65%). Conclusions There is wide heterogeneity among health care professionals regarding the clinical definition of coma and limited routine use of advanced coma assessment techniques in acute care settings. Coma management practices vary across sites, and mechanisms for coordinated and sustained follow-up after acute treatment are inconsistent. There is an urgent need for the development of evidence-based guidelines and a collaborative, coordinated approach to advance both the science and the practice of coma management globally. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01425-8.
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Affiliation(s)
- Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ettore Beghi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Harvard University, Boston, MA, USA.,Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Giuseppe Citerio
- Neuro-Intensive Care, ASST Di Monza, Monza, Italy.,School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY, USA
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Tarek Sharshar
- Neuro-Intensive Care Medicine, Sainte-Anne Hospital, University of Paris, GHU-Psychiatry & Neurosciences, Paris, France
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Hanno Ulmer
- Director Department of Medical Statistic, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Paul Vespa
- Departments of Neurology and Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Jennifer Frontera
- Department of Neurology, Grossman School of Medicine, New York University, New York, NY, USA
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Rass V, Ianosi BA, Lindner A, Kofler M, Schiefecker AJ, Pfausler B, Beer R, Schmutzhard E, Helbok R. Hemodynamic response during endotracheal suctioning predicts awakening and functional outcome in subarachnoid hemorrhage patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:432. [PMID: 32665009 PMCID: PMC7362501 DOI: 10.1186/s13054-020-03089-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/12/2020] [Indexed: 01/04/2023]
Abstract
Background Endotracheal suctioning (ES) provokes a cumulative hemodynamic response by activation of sympathetic and parasympathetic circuits in the central nervous system. In this proof-of-concept study, we aimed to analyze hemodynamic changes during ES in ventilated subarachnoid hemorrhage (SAH) patients and investigated whether the associated hemodynamic changes relate to the time to arousal and functional outcome. Methods For the current observational study, 191 SAH patients admitted to the neurological intensive care unit of a tertiary hospital requiring mechanical ventilation were included. One thousand eighty ES episodes during the first 72 h of admission were analyzed. Baseline median heart rate (HR) and mean arterial pressure (MAP) were compared to peak HR and MAP during ES based on 5-min averaged data (ΔHR and ΔMAP). Multivariable analysis to assess associations between ΔHR and ΔMAP and time to arousal (time to Richmond Agitation Sedation Scale ≥ 0, RASS) and poor functional outcome (modified Rankin Scale Score > 2, mRS) was performed using generalized estimating equations. Results Patients were 59 (IQR, 50–70) years old and presented with a median admission H&H grade of 4 (IQR, 3–5). In-hospital mortality was 22% (25% at 3 months) and median time to arousal was 13 (IQR, 4–21) days. HR increased by 2.3 ± 7.1 beats per minute (bpm) from 75.1 ± 14.8 bpm at baseline. MAP increased by 3.2 ± 7.8 mmHg from baseline 80.9 ± 9.8 mmHg. In multivariable analysis, ΔHR (p < 0.001) was significantly lower in patients who regained consciousness at a later time point and a lower ΔHR was associated with poor functional 3-month outcome independent of RASS (adjOR = 0.95; 95% CI = 0.93–0.98) or midazolam dose (adjOR = 0.96; 95% CI = 0.94–0.98). ΔMAP was neither associated with the time to regain consciousness (p = 0.087) nor with functional outcome (p = 0.263). Conclusion Augmentation in heart rate may quantify the hemodynamic response during endotracheal suctioning in brain-injured patients. The value as a biomarker to early discriminate the time to arousal and functional outcome in acutely brain-injured patients needs prospective confirmation.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bogdan-Andrei Ianosi
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Institute of Medical Informatics, UMIT, University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060, Hall, Austria
| | - Anna Lindner
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Mario Kofler
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alois J Schiefecker
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ronny Beer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Erich Schmutzhard
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Armstrong RA. Visual problems associated with traumatic brain injury. Clin Exp Optom 2018; 101:716-726. [PMID: 29488253 DOI: 10.1111/cxo.12670] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/12/2018] [Accepted: 01/17/2018] [Indexed: 12/14/2022] Open
Abstract
Traumatic brain injury (TBI) and its associated concussion are major causes of disability and death. All ages can be affected but children, young adults and the elderly are particularly susceptible. A decline in mortality has resulted in many more individuals living with a disability caused by TBI including those affecting vision. This review describes: (1) the major clinical and pathological features of TBI; (2) the visual signs and symptoms associated with the disorder; and (3) discusses the assessment of quality of life and visual rehabilitation of the patient. Defects in primary vision such as visual acuity and visual fields, eye movement including vergence, saccadic and smooth pursuit movements, and in more complex aspects of vision involving visual perception, motion vision ('akinopsia'), and visuo-spatial function have all been reported in TBI. Eye movement dysfunction may be an early sign of TBI. Hence, TBI can result in a variety of visual problems, many patients exhibiting multiple visual defects in combination with a decline in overall health. Patients with chronic dysfunction following TBI may require occupational, vestibular, cognitive and other forms of physical therapy. Such patients may also benefit from visual rehabilitation, including reading-related oculomotor training and the prescribing of spectacles with a variety of tints and prism combinations.
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