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Ding J, Ma X, Huang W, Yue C, Xu G, Wang Y, Sheng S, Liu M, Ren Y. Validation and refinement of a predictive nomogram using artificial intelligence: assessing in-hospital mortality in patients with large hemispheric cerebral infarction. Front Neurol 2024; 15:1398142. [PMID: 38984035 PMCID: PMC11231922 DOI: 10.3389/fneur.2024.1398142] [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: 03/11/2024] [Accepted: 06/14/2024] [Indexed: 07/11/2024] Open
Abstract
Background Large Hemispheric Infarction (LHI) poses significant mortality and morbidity risks, necessitating predictive models for in-hospital mortality. Previous studies have explored LHI progression to malignant cerebral edema (MCE) but have not comprehensively addressed in-hospital mortality risk, especially in non-decompressive hemicraniectomy (DHC) patients. Methods Demographic, clinical, risk factor, and laboratory data were gathered. The population was randomly divided into Development and Validation Groups at a 3:1 ratio, with no statistically significant differences observed. Variable selection utilized the Bonferroni-corrected Boruta technique (p < 0.01). Logistic Regression retained essential variables, leading to the development of a nomogram. ROC and DCA curves were generated, and calibration was conducted based on the Validation Group. Results This study included 314 patients with acute anterior-circulating LHI, with 29.6% in the Death group (n = 93). Significant variables, including Glasgow Coma Score, Collateral Score, NLR, Ventilation, Non-MCA territorial involvement, and Midline Shift, were identified through the Boruta algorithm. The final Logistic Regression model led to a nomogram creation, exhibiting excellent discriminative capacity. Calibration curves in the Validation Group showed a high degree of conformity with actual observations. DCA curve analysis indicated substantial clinical net benefit within the 5 to 85% threshold range. Conclusion We have utilized NIHSS score, Collateral Score, NLR, mechanical ventilation, non-MCA territorial involvement, and midline shift to develop a highly accurate, user-friendly nomogram for predicting in-hospital mortality in LHI patients. This nomogram serves as valuable reference material for future studies on LHI patient prognosis and mortality prevention, while addressing previous research limitations.
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Affiliation(s)
- Jian Ding
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiaoming Ma
- Department of Neurology, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou, China
| | - Wendie Huang
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Chunxian Yue
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Geman Xu
- Department of Neurology, Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang, China
| | - Yumei Wang
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Shiying Sheng
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Meng Liu
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yi Ren
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
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Nong J, Glassman PM, Shuvaev VV, Reyes-Esteves S, Descamps HC, Kiseleva RY, Papp TE, Alameh MG, Tam YK, Mui BL, Omo-Lamai S, Zamora ME, Shuvaeva T, Arguiri E, Gong X, Brysgel TV, Tan AW, Woolfork AG, Weljie A, Thaiss CA, Myerson JW, Weissman D, Kasner SE, Parhiz H, Muzykantov VR, Brenner JS, Marcos-Contreras OA. Targeting lipid nanoparticles to the blood-brain barrier to ameliorate acute ischemic stroke. Mol Ther 2024; 32:1344-1358. [PMID: 38454606 PMCID: PMC11081939 DOI: 10.1016/j.ymthe.2024.03.004] [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: 08/07/2023] [Revised: 01/28/2024] [Accepted: 03/05/2024] [Indexed: 03/09/2024] Open
Abstract
Effective delivery of mRNA or small molecule drugs to the brain is a significant challenge in developing treatment for acute ischemic stroke (AIS). To address the problem, we have developed targeted nanomedicine to increase drug concentrations in endothelial cells of the blood-brain barrier (BBB) of the injured brain. Inflammation during ischemic stroke causes continuous neuronal death and an increase in the infarct volume. To enable targeted delivery to the inflamed BBB, we conjugated lipid nanocarriers (NCs) with antibodies that bind cell adhesion molecules expressed at the BBB. In the transient middle cerebral artery occlusion mouse model, NCs targeted to vascular cellular adhesion molecule-1 (VCAM) achieved the highest level of brain delivery, nearly two orders of magnitude higher than untargeted ones. VCAM-targeted lipid nanoparticles with luciferase-encoding mRNA and Cre-recombinase showed selective expression in the ischemic brain. Anti-inflammatory drugs administered intravenously after ischemic stroke reduced cerebral infarct volume by 62% (interleukin-10 mRNA) or 35% (dexamethasone) only when they were encapsulated in VCAM-targeted NCs. Thus, VCAM-targeted lipid NCs represent a new platform for strongly concentrating drugs within the compromised BBB of penumbra, thereby ameliorating AIS.
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Affiliation(s)
- Jia Nong
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Patrick M Glassman
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Pharmaceutical Sciences, School of Pharmacy, Temple University, Philadelphia, PA, USA
| | - Vladimir V Shuvaev
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sahily Reyes-Esteves
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Helene C Descamps
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Raisa Y Kiseleva
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tyler E Papp
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamad-Gabriel Alameh
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ying K Tam
- Acuitas Therapeutics, Vancouver, British Columbia V6T 1Z3, Canada
| | - Barbara L Mui
- Acuitas Therapeutics, Vancouver, British Columbia V6T 1Z3, Canada
| | - Serena Omo-Lamai
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Marco E Zamora
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tea Shuvaeva
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Evguenia Arguiri
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Xijing Gong
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Taylor V Brysgel
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ai Wen Tan
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ashley G Woolfork
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Aalim Weljie
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Christoph A Thaiss
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacob W Myerson
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Drew Weissman
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hamideh Parhiz
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Vladimir R Muzykantov
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Jacob S Brenner
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Pulmonary Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Oscar A Marcos-Contreras
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Tang A, Ma X, Ren Y, Zhang H, Xie W, Liu M, Sheng S, Mao K. External validation and comparison of MBE, EDEMA, and modified EDEMA scores for predicting malignant cerebral EDEMA in Chinese patients with large hemispheric infarction patients without revascularization. J Clin Neurosci 2024; 122:66-72. [PMID: 38489953 DOI: 10.1016/j.jocn.2024.03.005] [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: 10/09/2023] [Revised: 03/02/2024] [Accepted: 03/06/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Malignant cerebral edema (MCE) is a severe condition characterized by rapid neurological deterioration and a potentially poor prognosis. Scoring systems including the malignant brain edema (MBE) score, Enhanced Detection of Edema in Malignant Anterior Circulation Stroke score (EDEMA), and modified EDEMA score, have been developed to predict MCE in patients with large hemispheric infarction (LHI). We aimed to externally validate and comparethe predictive efficacy of these scores in LHI patients within 48 h of onset and not undergoing reperfusion therapy. METHODS Demographic, clinical and radiological data were retrospectively collected from LHI patients within 48 h of onset and not receiving reperfusion therapy. Patients were divided into MCE and non-MCE group. The calibration, discrimination, and clinical practicability of the three scores were verified using Hosmer-Lemeshow goodness-of-fit test, receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA), respectively. Finally, continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were applied to determine the discrimination performance of the three scores. RESULTS A total of 314 patients were included in the study, with 122 cases being MCE patients. The Hosmer-Lemeshow goodness-of-fit test showed excellent fitting ability across the MBE (p = 0.36), EDEMA (p = 0.61), and modified EDEMA scores (p = 0.62) in our patients. The MBE, EDEMA, and modified EDEMA scores had the AUCs of 0.855 (95 % CI 0.818-0.898), 0.782 (95 % CI 0.727-0.837) and 0.878 (95 % CI 0.844-0.919) respectively. The MBE (NRI, 0.33; 95 % CI, 0.11-0.56, p = 0.003 and IDI, 0.11; 95 % CI, 0.03-0.18; p = 0.004) and modified EDEMA scores (NRI, 1.10; 95 % CI, 0.94-1.26; p < 0.001 and IDI, 0.17; 95 % CI, 0.13-0.20, p < 0.001) showed better performance than the EDEMA score. DCA demonstrated that the modified EDEMA score outperformed the other two scores, possessing heightened clinical usefulness. CONCLUSIONS The MBE, EDEMA, and modified EDEMA scores for predicting MCE are also applicable in non-revascularization LHI patients within 48 h of onset. Both the MBE and modified EDEMA scores demonstrated higher predictive validity as predictive tools for MCE in LHI patients than the EDEMA score. Furthermore, the modified EDEMA score could be a suitable prediction tool in Chinese patients for its excellent clinical utility.
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Affiliation(s)
- Anqi Tang
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiaoming Ma
- North China University of Science and Technology, Tangshan, China
| | - Yi Ren
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Hao Zhang
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Wei Xie
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Meng Liu
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China.
| | - Shiying Sheng
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China.
| | - Keshi Mao
- Department of Neurology, The Third Affiliated Hospital of Soochow University, Changzhou, China.
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Geiseler SJ, Hadzic A, Lambertus M, Forbord KM, Sajedi G, Liesz A, Morland C. L-Lactate Treatment at 24 h and 48 h after Acute Experimental Stroke Is Neuroprotective via Activation of the L-Lactate Receptor HCA 1. Int J Mol Sci 2024; 25:1232. [PMID: 38279234 PMCID: PMC10816130 DOI: 10.3390/ijms25021232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 01/28/2024] Open
Abstract
Stroke is the main cause for acquired disabilities. Pharmaceutical or mechanical removal of the thrombus is the cornerstone of stroke treatment but can only be administered to a subset of patients and within a narrow time window. Novel treatment options are therefore required. Here we induced stroke by permanent occlusion of the distal medial cerebral artery of wild-type mice and knockout mice for the lactate receptor hydroxycarboxylic acid receptor 1 (HCA1). At 24 h and 48 h after stroke induction, we injected L-lactate intraperitoneal. The resulting atrophy was measured in Nissl-stained brain sections, and capillary density and neurogenesis were measured after immunolabeling and confocal imaging. In wild-type mice, L-lactate treatment resulted in an HCA1-dependent reduction in the lesion volume accompanied by enhanced angiogenesis. In HCA1 knockout mice, on the other hand, there was no increase in angiogenesis and no reduction in lesion volume in response to L-lactate treatment. Nevertheless, the lesion volumes in HCA1 knockout mice-regardless of L-lactate treatment-were smaller than in control mice, indicating a multifactorial role of HCA1 in stroke. Our findings suggest that L-lactate administered 24 h and 48 h after stroke is protective in stroke. This represents a time window where no effective treatment options are currently available.
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Affiliation(s)
- Samuel J. Geiseler
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, 0316 Oslo, Norway; (A.H.); (M.L.); (K.M.F.); (G.S.)
| | - Alena Hadzic
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, 0316 Oslo, Norway; (A.H.); (M.L.); (K.M.F.); (G.S.)
| | - Marvin Lambertus
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, 0316 Oslo, Norway; (A.H.); (M.L.); (K.M.F.); (G.S.)
| | - Karl Martin Forbord
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, 0316 Oslo, Norway; (A.H.); (M.L.); (K.M.F.); (G.S.)
| | - Ghazal Sajedi
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, 0316 Oslo, Norway; (A.H.); (M.L.); (K.M.F.); (G.S.)
| | - Arthur Liesz
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians University Munich, 81377 Munich, Germany;
- Graduate School of Systemic Neurosciences Munich, 82152 Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), 81377 Munich, Germany
| | - Cecilie Morland
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, 0316 Oslo, Norway; (A.H.); (M.L.); (K.M.F.); (G.S.)
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Schoene D, Hartmann C, Winzer S, Moustafa H, Günther A, Puetz V, Barlinn K. [Postoperative management following decompressive hemicraniectomy for malignant middle cerebral artery infarction-A German nationwide survey study]. DER NERVENARZT 2023; 94:934-943. [PMID: 37140605 PMCID: PMC10157548 DOI: 10.1007/s00115-023-01486-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Malignant middle cerebral artery infarction is a potentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60 years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization. OBJECTIVE This survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting. MATERIAL AND METHODS From 20 September 2021 to 31 October 2021, 43 members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in a standardized anonymous online survey. Descriptive data analysis was performed. RESULTS Out of 43 centers 29 (67.4%) participated in the survey, including 24 university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored a standardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3 days in 30.8%, ≤ 5 days in 19.2%, > 5 days in 15.4%). Early tracheotomy (≤ 7 days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14 days. Hyperosmolar treatment is used on a regular basis in 53.9% and 22 centers (84.6%) agreed to participate in a clinical trial addressing the duration of postoperative sedation and ventilation. CONCLUSION The results of this nationwide survey among neurointensive care units in Germany reflect a remarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. A randomized trial in this matter seems warranted.
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Affiliation(s)
- D Schoene
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland.
| | - C Hartmann
- Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - S Winzer
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - H Moustafa
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - A Günther
- Klinik für Neurologie, Universitätsklinikum Jena, Jena, Deutschland
| | - V Puetz
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - K Barlinn
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
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Chen C, Yang J, Han Q, Wu Y, Li J, Xu T, Sun J, Gao X, Huang Y, Parsons MW, Lin L. Net water uptake within the ischemic penumbra predicts the presence of the midline shift in patients with acute ischemic stroke. Front Neurol 2023; 14:1246775. [PMID: 37840922 PMCID: PMC10570612 DOI: 10.3389/fneur.2023.1246775] [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: 06/24/2023] [Accepted: 08/25/2023] [Indexed: 10/17/2023] Open
Abstract
Objective The study aimed to explore the association between midline shift (MLS) and net water uptake (NWU) within the ischemic penumbra in acute ischemic stroke patients. Methods This was a retrospective cohort study that examined patients with anterior circulation stroke. Net water uptake within the acute ischemic core and penumbra was calculated using data from admission multimodal CT scans. The primary outcome was severe cerebral edema measured by the presence of MLS on 24 to 48 h follow-up CT scans. The presence of a significant MLS was defined by a deviation of the septum pellucidum from the midline on follow-up CT scans of at least 3 mm or greater due to the mass effect of ischemic edema. The net water uptake was compared between patients with and without MLS, followed by logistic regression analyses and receiver operating characteristics (ROCs) to assess the predictive power of net water uptake in MLS. Results A total of 133 patients were analyzed: 50 patients (37.6%) with MLS and 83 patients (62.4%) without. Compared to patients without MLS, patients with MLS had higher net water uptake within the core [6.8 (3.2-10.4) vs. 4.9 (2.2-8.1), P = 0.048] and higher net water uptake within the ischemic penumbra [2.9 (1.8-4.3) vs. 0.2 (-2.5-2.7), P < 0.001]. Penumbral net water uptake had higher predictive performance than net water uptake of the core in MLS [area under the curve: 0.708 vs. 0.603, p < 0.001]. Moreover, the penumbral net water uptake predicted MLS in the multivariate regression model, adjusting for age, sex, admission National Institutes of Health Stroke Scale (NIHSS), diabetes mellitus, atrial fibrillation, ischemic core volume, and poor collateral vessel status (OR = 1.165; 95% CI = 1.002-1.356; P = 0.047). No significant prediction was found for the net water uptake of the core in the multivariate regression model. Conclusion Net water uptake measured acutely within the ischemic penumbra could predict severe cerebral edema at 24-48 h.
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Affiliation(s)
- Cuiping Chen
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jianhong Yang
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Qing Han
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yuefei Wu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jichuan Li
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Tianqi Xu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jie Sun
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Xiang Gao
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yi Huang
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Mark W. Parsons
- Department of Neurology, Liverpool Hospital, Sydney, NSW, Australia
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
| | - Longting Lin
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
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7
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Batur A, Karaca MA, Arslan V, Boz M, Ibrahimov Z, Erbil B, Onur MR. Prognostic role of optic nerve sheath diameter in stroke in emergency department, A case control study. Niger J Clin Pract 2023; 26:863-870. [PMID: 37635568 DOI: 10.4103/njcp.njcp_1770_21] [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: 08/29/2023]
Abstract
Background Sonographic measurement of optic nerve sheath diameter (ONSD) can reflect intracranial pressure (ICP) indirectly and determine the neurology intensive care unit (NICU) requirement and mortality in acute ischemic stroke (AIS). Aim To demonstrate the effectiveness of ONSD to determine mortality, morbidity, and NICU requirement on patients with the AIS. Methods The sonographic ONSD measurements were performed on each patient with AIS, over 18 years old. All patients were categorized according to the Oxfordshire Community Stroke Project (OCSP) classification system. MRI images were examined for increased ICP, and the patients were categorized into two groups as increased ICP (i-ICP) and normal ICP. The ONSD results were evaluated in terms of classifications, outcomes, and prognosis of the patients. Results One hundred and five patients were included and 31 (35.2%) were in the i-ICP group. The median ONSDs were 5.26 mm in the i-ICP group and 4.62 mm in the normal ICP group (P < 0.001). The median ONSDs were 5.13 mm in the NICU group and 4.69 mm in the neurology ward (NW) group (P = 0.001). The total anterior circulation infarction (TACI) subgroup had higher ONSDs than the others (TACI: 5.27 mm; PACI: 4.73 mm; POCI: 4.77 mm; and LACI: 4.64 mm, P < 0.001). The NICU requirements were higher in the TACI subgroup. The median ONSD was 5.42 mm in the deceased group (survived: 4.77 mm, P < 0.001). Conclusion ONSD may be favorable for predicting the increased ICP and the NICU requirement in OCSP subgroups. Moreover, ONSD can be used to foresee the mortality of AIS.
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Affiliation(s)
- A Batur
- Department of Emergency Medicine, Hacettepe University, Faculty of Medicine, 06120 Altindag Ankara, Turkey
| | - M A Karaca
- Department of Emergency Medicine, Hacettepe University, Faculty of Medicine, 06120 Altindag Ankara, Turkey
| | - V Arslan
- Department of Emergency Medicine, Hacettepe University, Faculty of Medicine, 06120 Altindag Ankara, Turkey
| | - M Boz
- Department of Emergency Medicine, Hacettepe University, Faculty of Medicine, 06120 Altindag Ankara, Turkey
| | - Z Ibrahimov
- Department of Emergency Medicine, Hacettepe University, Faculty of Medicine, 06120 Altindag Ankara, Turkey
| | - B Erbil
- Department of Emergency Medicine, Hacettepe University, Faculty of Medicine, 06120 Altindag Ankara, Turkey
| | - M R Onur
- Radiology, Hacettepe University, Faculty of Medicine, 06120 Altindag Ankara, Turkey
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Naik A, Adeleye O, Koester SW, Winkler EA, Hartke JN, Karahalios K, Mihaljevic S, Rani A, Raikwar S, Rulney JD, Desai SM, Scherschinski L, Ducruet AF, Albuquerque FC, Lawton MT, Catapano JS, Jadhav AP, Jha RM. Cerebrospinal Fluid Biomarkers for Diagnosis and the Prognostication of Acute Ischemic Stroke: A Systematic Review. Int J Mol Sci 2023; 24:10902. [PMID: 37446092 DOI: 10.3390/ijms241310902] [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: 02/10/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Despite the high incidence and burden of stroke, biological biomarkers are not used routinely in clinical practice to diagnose, determine progression, or prognosticate outcomes of acute ischemic stroke (AIS). Because of its direct interface with neural tissue, cerebrospinal fluid (CSF) is a potentially valuable source for biomarker development. This systematic review was conducted using three databases. All trials investigating clinical and preclinical models for CSF biomarkers for AIS diagnosis, prognostication, and severity grading were included, yielding 22 human trials and five animal studies for analysis. In total, 21 biomarkers and other multiomic proteomic markers were identified. S100B, inflammatory markers (including tumor necrosis factor-alpha and interleukin 6), and free fatty acids were the most frequently studied biomarkers. The review showed that CSF is an effective medium for biomarker acquisition for AIS. Although CSF is not routinely clinically obtained, a potential benefit of CSF studies is identifying valuable biomarkers from the pathophysiologic microenvironment that ultimately inform optimization of targeted low-abundance assays from peripheral biofluid samples (e.g., plasma). Several important catabolic and anabolic markers can serve as effective measures of diagnosis, etiology identification, prognostication, and severity grading. Trials with large cohorts studying the efficacy of biomarkers in altering clinical management are still needed.
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Affiliation(s)
- Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Champaign, IL 61820, USA
| | - Olufunmilola Adeleye
- Mayo Clinic Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Sandra Mihaljevic
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Anupama Rani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Sudhanshu Raikwar
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Jarrod D Rulney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Shashvat M Desai
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
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9
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Nong J, Glassman PM, Reyes-Esteves S, Descamps HC, Shuvaev VV, Kiseleva RY, Papp TE, Alameh MG, Tam YK, Mui BL, Omo-Lamai S, Zamora ME, Shuvaeva T, Arguiri E, Thaiss CA, Myerson JW, Weissman D, Kasner SE, Parhiz H, Muzykantov VR, Brenner JS, Marcos-Contreras OA. Targeting lipid nanoparticles to the blood brain barrier to ameliorate acute ischemic stroke. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.06.12.544645. [PMID: 37398465 PMCID: PMC10312645 DOI: 10.1101/2023.06.12.544645] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
After more than 100 failed drug trials for acute ischemic stroke (AIS), one of the most commonly cited reasons for the failure has been that drugs achieve very low concentrations in the at-risk penumbra. To address this problem, here we employ nanotechnology to significantly enhance drug concentration in the penumbra's blood-brain barrier (BBB), whose increased permeability in AIS has long been hypothesized to kill neurons by exposing them to toxic plasma proteins. To devise drug-loaded nanocarriers targeted to the BBB, we conjugated them with antibodies that bind to various cell adhesion molecules on the BBB endothelium. In the transient middle cerebral artery occlusion (tMCAO) mouse model, nanocarriers targeted with VCAM antibodies achieved the highest level of brain delivery, nearly 2 orders of magnitude higher than untargeted ones. VCAM-targeted lipid nanoparticles loaded with either a small molecule drug (dexamethasone) or mRNA (encoding IL-10) reduced cerebral infarct volume by 35% or 73%, respectively, and both significantly lowered mortality rates. In contrast, the drugs delivered without the nanocarriers had no effect on AIS outcomes. Thus, VCAM-targeted lipid nanoparticles represent a new platform for strongly concentrating drugs within the compromised BBB of penumbra, thereby ameliorating AIS. Graphical abstract Acute ischemic stroke induces upregulation of VCAM. We specifically targeted upregulated VCAM in the injured region of the brain with drug- or mRNA-loaded targeted nanocarriers. Nanocarriers targeted with VCAM antibodies achieved the highest brain delivery, nearly orders of magnitude higher than untargeted ones. VCAM-targeted nanocarriers loaded with dexamethasone and mRNA encoding IL-10 reduced infarct volume by 35% and 73%, respectively, and improved survival rates.
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10
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Okonkwo ON, Agweye CT, Akanbi T. Neuroprotection for Nonarteritic Central Retinal Artery Occlusion: Lessons from Acute Ischemic Stroke. Clin Ophthalmol 2023; 17:1531-1543. [PMID: 37284058 PMCID: PMC10239763 DOI: 10.2147/opth.s403433] [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: 01/03/2023] [Accepted: 05/19/2023] [Indexed: 06/08/2023] Open
Abstract
Nonarteritic central retinal artery occlusion (NA-CRAO) is a variant of acute ischemic stroke (AIS) and is a cause of sudden severe loss of vision. There are guidelines by the American Heart Association and the American Stroke Association for the care of CRAO patients. This review explores the basis of retinal neuroprotection for CRAO and its potential for improving the outcome of NA-CRAO. Recently, there have been significant advances in research into the use of neuroprotection to treat retinal diseases, including retinal detachment, age-related macular degeneration, and inherited retinal diseases. Also, neuroprotective research in AIS has been extensive, and newer drugs tested, including Uric acid, Nerinetide, and Otaplimastat, with promising results. Progress in cerebral neuroprotection after AIS offers hope for retinal neuroprotection after CRAO; and a possibility of extrapolating research findings from AIS into CRAO. Combining neuroprotection and thrombolysis can extend the therapeutic window for NA-CRAO treatment and potentially improve outcomes. Experimented neuroprotection for CRAO includes Angiopoietin (Comp Ang1), KUS 121, Gene therapy (XIAP), and hypothermia. Efforts in the field of neuroprotection for NA-CRAO should focus on better imaging to delineate the penumbra after an acute episode of NA-CRAO (using a combination of high-definition optical coherence angiography and electrophysiology). Also, research should explore details of pathophysiologic mechanisms involved in NA-CRAO, allowing for further neuroprotective intervention, and closing the gap between preclinical and clinical neuroprotection.
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Affiliation(s)
- Ogugua Ndubuisi Okonkwo
- Department of Ophthalmology, Eye Foundation Hospital and Eye Foundation Retina Institute, Ikeja, Lagos, Nigeria
| | - Chineze Thelma Agweye
- Department of Ophthalmology, University of Calabar and University of Calabar Teaching Hospital, Cross River, Nigeria
| | - Toyin Akanbi
- Department of Ophthalmology, Eye Foundation Hospital and Eye Foundation Retina Institute, Ikeja, Lagos, Nigeria
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11
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Schneider AM, Neuhaus AA, Hadley G, Balami JS, Harston GW, DeLuca GC, Buchan AM. Posterior circulation ischaemic stroke diagnosis and management. Clin Med (Lond) 2023; 23:219-227. [PMID: 37236792 PMCID: PMC11046504 DOI: 10.7861/clinmed.2022-0499] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This narrative review provides an overview of the posterior circulation and the clinical features of common posterior circulation stroke (PCS) syndromes in the posterior arterial territories and how to distinguish them from mimics. We outline the hyperacute management of patients with suspected PCS with emphasis on how to identify those who are likely to benefit from intervention based on imaging findings. Finally, we review advances in treatment options, including developments in endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT), and the principles of medical management and indications for neurosurgery. Observational and randomised clinical trial data have been equivocal regarding EVT in PCS, but more recent studies strongly support its efficacy. There have been concomitant advances in imaging of posterior stroke to guide optimal patient selection for thrombectomy. Recent evidence suggests that clinicians should have a heightened suspicion of posterior circulation events with the resultant implementation of timely, evidence-based management.
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Affiliation(s)
| | | | | | - Joyce S Balami
- University of Oxford, Oxford, UK, and consultant stroke physician, Norfolk and Norwich University Teaching Hospital NHS Trust, Norwich, UK
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12
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Maheshwari S, Dwyer LJ, Sîrbulescu RF. Inflammation and immunomodulation in central nervous system injury - B cells as a novel therapeutic opportunity. Neurobiol Dis 2023; 180:106077. [PMID: 36914074 PMCID: PMC10758988 DOI: 10.1016/j.nbd.2023.106077] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 03/13/2023] Open
Abstract
Acute injury to the central nervous system (CNS) remains a complex and challenging clinical need. CNS injury initiates a dynamic neuroinflammatory response, mediated by both resident and infiltrating immune cells. Following the primary injury, dysregulated inflammatory cascades have been implicated in sustaining a pro-inflammatory microenvironment, driving secondary neurodegeneration and the development of lasting neurological dysfunction. Due to the multifaceted nature of CNS injury, clinically effective therapies for conditions such as traumatic brain injury (TBI), spinal cord injury (SCI), and stroke have proven challenging to develop. No therapeutics that adequately address the chronic inflammatory component of secondary CNS injury are currently available. Recently, B lymphocytes have gained increasing appreciation for their role in maintaining immune homeostasis and regulating inflammatory responses in the context of tissue injury. Here we review the neuroinflammatory response to CNS injury with particular focus on the underexplored role of B cells and summarize recent results on the use of purified B lymphocytes as a novel immunomodulatory therapeutic for tissue injury, particularly in the CNS.
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Affiliation(s)
- Saumya Maheshwari
- Vaccine and Immunotherapy Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Liam J Dwyer
- Vaccine and Immunotherapy Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ruxandra F Sîrbulescu
- Vaccine and Immunotherapy Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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13
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Lee YI, Ahn J, Ryu JA. Clinical Outcomes Associated with Degree of Hypernatremia in Neurocritically Ill Patients. J Korean Neurosurg Soc 2023; 66:95-104. [PMID: 36124364 PMCID: PMC9837482 DOI: 10.3340/jkns.2022.0161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/10/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Hypernatremia is a common complication encountered during the treatment of neurocritically ill patients. However, it is unclear whether clinical outcomes correlate with the severity of hypernatremia in such patients. Therefore, we investigated the impact of hypernatremia on mortality of these patients, depending on the degree of hypernatremia. METHODS Among neurosurgical patients admitted to the intensive care unit (ICU) in a tertiary hospital from January 2013 to December 2019, patients who were hospitalized in the ICU for more than 5 days and whose serum sodium levels were obtained during ICU admission were included. Hypernatremia was defined as the highest serum sodium level exceeding 150 mEq/L observed. We classified the patients into four subgroups according to the severity of hypernatremia and performed propensity score matching analysis. RESULTS Among 1146 patients, 353 patients (30.8%) showed hypernatremia. Based on propensity score matching, 290 pairs were included in the analysis. The hypernatremia group had higher rates of in-hospital mortality and 28-day mortality in both overall and matched population (both p<0.001 and p=0.001, respectively). In multivariable analysis of propensity score-matched population, moderate and severe hypernatremia were significantly associated with in-hospital mortality (adjusted odds ratio [OR], 4.58; 95% confidence interval [CI], 2.15-9.75 and adjusted OR, 6.93; 95% CI, 3.46-13.90, respectively) and 28-day mortality (adjusted OR, 3.51; 95% CI, 1.54-7.98 and adjusted OR, 10.60; 95% CI, 5.10-21.90, respectively) compared with the absence of hypernatremia. However, clinical outcomes, including in-hospital mortality and 28-day mortality, were not significantly different between the group without hypernatremia and the group with mild hypernatremia (p=0.720 and p=0.690, respectively). The mortality rates of patients with moderate and severe hypernatremia were significantly higher in both overall and matched population. Interestingly, the mild hypernatremia group of matched population showed the best survival rate. CONCLUSION Moderate and severe hypernatremia were associated with poor clinical outcomes in neurocritically ill patients. However, the prognosis of patients with mild hypernatremia was similar with that of patients without hypernatremia. Therefore, mild hypernatremia may be allowed during treatment of intracranial hypertension using hyperosmolar therapy.
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Affiliation(s)
- Yun Im Lee
- Department of Internal Medicine, National Cancer Center, Goyang, Korea
| | - Joonghyun Ahn
- Statistic and Data Center, Clinical Research Institute, Samsung Medical Center, Seoul, Korea
| | - Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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14
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Ha GH, Kim EJ, Park JS, Kim JE, Nam H, Yeon JY, Lee SH, Lee K, Kim CK, Joo KM. JAK2/STAT3 pathway mediates neuroprotective and pro-angiogenic treatment effects of adult human neural stem cells in middle cerebral artery occlusion stroke animal models. Aging (Albany NY) 2022; 14:8944-8969. [PMID: 36446389 PMCID: PMC9740376 DOI: 10.18632/aging.204410] [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: 09/09/2022] [Accepted: 11/17/2022] [Indexed: 12/03/2022]
Abstract
Mismatches between pre-clinical and clinical results of stem cell therapeutics for ischemic stroke limit their clinical applicability. To overcome these discrepancies, precise planning of pre-clinical experiments that can be translated to clinical trials and the scientific elucidation of treatment mechanisms is important. In this study, adult human neural stem cells (ahNSCs) derived from temporal lobe surgical samples were used (to avoid ethical and safety issues), and their therapeutic effects on ischemic stroke were examined using middle cerebral artery occlusion animal models. 5 × 105 ahNSCs was directly injected into the lateral ventricle of contralateral brain hemispheres of immune suppressed rat stroke models at the subacute phase of stroke. Compared with the mock-treated group, ahNSCs reduced brain tissue atrophy and neurological sensorimotor and memory functional loss. Tissue analysis demonstrated that the significant therapeutic effects were mediated by the neuroprotective and pro-angiogenic activities of ahNSCs, which preserved neurons in ischemic brain areas and decreased reactive astrogliosis and microglial activation. The neuroprotective and pro-angiogenic effects of ahNSCs were validated in in vitro stroke models and were induced by paracrine factors excreted by ahNSCs. When the JAK2/STAT3 signaling pathway was inhibited by a specific inhibitor, AG490, the paracrine neuroprotective and pro-angiogenic effects of ahNSCs were reversed. This pre-clinical study that closely simulated clinical settings and provided treatment mechanisms of ahNSCs for ischemic stroke may aid the development of protocols for subsequent clinical trials of ahNSCs and the realization of clinically available stem cell therapeutics for ischemic stroke.
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Affiliation(s)
- Geun-Hyoung Ha
- Medical Innovation Technology Inc. (MEDINNO Inc.), Seoul 08513, South Korea
| | - Eun Ji Kim
- Medical Innovation Technology Inc. (MEDINNO Inc.), Seoul 08513, South Korea
| | - Jee Soo Park
- Department of Anatomy and Cell Biology, Sungkyunkwan University School of Medicine, Suwon 16419, South Korea
| | - Ji Eun Kim
- Medical Innovation Technology Inc. (MEDINNO Inc.), Seoul 08513, South Korea
| | - Hyun Nam
- Medical Innovation Technology Inc. (MEDINNO Inc.), Seoul 08513, South Korea,Stem Cell and Regenerative Medicine Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul 06351, South Korea,Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Sun-Ho Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul 06351, South Korea
| | - Kyunghoon Lee
- Department of Anatomy and Cell Biology, Sungkyunkwan University School of Medicine, Suwon 16419, South Korea,Single Cell Network Research Center, Sungkyunkwan University School of Medicine, Suwon 16149, South Korea,Biomedical Institute for Convergence at SKKU (BICS), Sungkyunkwan University, Suwon 16419, South Korea
| | - Chung Kwon Kim
- Medical Innovation Technology Inc. (MEDINNO Inc.), Seoul 08513, South Korea,Biomedical Institute for Convergence at SKKU (BICS), Sungkyunkwan University, Suwon 16419, South Korea
| | - Kyeung Min Joo
- Medical Innovation Technology Inc. (MEDINNO Inc.), Seoul 08513, South Korea,Department of Anatomy and Cell Biology, Sungkyunkwan University School of Medicine, Suwon 16419, South Korea,Stem Cell and Regenerative Medicine Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul 06351, South Korea,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul 06351, South Korea,Single Cell Network Research Center, Sungkyunkwan University School of Medicine, Suwon 16149, South Korea,Biomedical Institute for Convergence at SKKU (BICS), Sungkyunkwan University, Suwon 16419, South Korea
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15
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Guo Y, Chen Y, Shen C, Fan D, Hu X, Duan J, Chen Y. Optic nerve sheath diameter and optic nerve sheath diameter/eyeball transverse diameter ratio in prediction of malignant progression in ischemic stroke. Front Neurol 2022; 13:998389. [PMID: 36158954 PMCID: PMC9493305 DOI: 10.3389/fneur.2022.998389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/15/2022] [Indexed: 12/05/2022] Open
Abstract
Background The optic nerve sheath diameter (ONSD)/eyeball transverse diameter (ETD) ratio has been suggested in the evaluation of intracranial pressure (ICP). The aim of this study was to evaluate the predictive value of ONSD and ONSD/ETD in relation to risk for secondary malignant middle cerebral artery infarction (MMI). Methods A total of 91 patients with MCA occlusion were included in this study. Data were divided into two groups based on development of MMI or not. ONSD and ETD were measured by unenhanced computed tomography (CT). The differences in ONSD and the ONSD/ETD ratios between the MMI and non-MMI groups were compared. Receiver operating characteristic curve analyses were used to test the diagnostic value of ONSD and ONSD/ETD independently, to predict MMI. Results The ONSD in the MMI group and non-MMI group were 5.744 ± 0.140 mm and 5.443 ± 0.315 mm, respectively (P = 0.001). In addition, the ONSD/ETD ratios in the MMI group and non-MMI group were 0.258 ± 0.008 and 0.245 ± 0.006, respectively (P = 0.001). The receiver operating characteristic (ROC) curve demonstrated an area under the curve (AUC) for ONSD of 0.812 [95% confidence interval (CI): 0.718–0.906, P = 0.001], with a sensitivity of 97.4% and a specificity of 66.0% at the cut-off value of 5.520 mm. The AUC for ONSD/ETD ratio in predicting occurrence of MMI was 0.895 (95% CI: 0.823–0.968, P = 0.001), with a sensitivity of 84.2% and a specificity of 92.5% at a cut-off value of 0.250. Conclusion In acute stroke patients with massive cerebral infarction, an increased ONSD or ONSD/ETD ratio increases the odds of malignant progression and may be used as an indicator for emergent therapeutic interventions. In addition, the ONSD/ETD ratio may be more valuable than ONSD in predicting the malignant progression of acute stroke patients.
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16
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Pilato F, Pellegrino G, Calandrelli R, Broccolini A, Marca GD, Frisullo G, Morosetti R, Profice P, Brunetti V, Capone F, D'Apolito G, Quinci V, Albanese A, Mangiola A, Marchese E, Pompucci A, Di Lazzaro V. Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: A real-world study. J Neurol Sci 2022; 441:120376. [DOI: 10.1016/j.jns.2022.120376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/03/2022] [Accepted: 07/31/2022] [Indexed: 10/16/2022]
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17
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Lu W, Jia D, Qin Y. Decompressive craniectomy combined with temporal pole resection in the treatment of massive cerebral infarction. BMC Neurol 2022; 22:167. [PMID: 35501820 PMCID: PMC9063210 DOI: 10.1186/s12883-022-02688-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/25/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and prognosis of decompressive craniectomy combined with temporal pole resection in the treatment of massive cerebral infarction, in order to provide basis for treatment selection. METHODS The clinical data of the patient with massive cerebral infarction treated in our hospital from January 2015 to December 2018 were analyzed retrospectively. According to the surgical methods, the patients were divided into control group (decompressive craniectomy) and study group (decompressive craniectomy + temporal pole resection). Intracranial pressure monitoring devices were placed in both groups. The NIHSS scores of the two groups before and 14 days after operation, the changes of intracranial pressure, length of hospital stay, length of NICU, mortality and modified Rankin scale before and after treatment were compared between the two groups. RESULTS The NIHSS score of the two groups after operation was lower than that before operation, and the NIHSS score of the study group was significantly lower than that of the control group (P < 0.05); The intracranial pressure in the study group was significantly lower than that in the control group (P < 0.05); One month after operation, the mortality of the study group (13.0%) was lower than that of the control group (27.8%). After one year of follow-up, the mortality of the study group (21.7%) was significantly lower than that of the control group (38.8%) (P < 0.05); The scores of mRS in the two groups were significantly improved compared with those before treatment (P < 0.05), and the scores of mRS in the study group were better than those in the control group (P < 0.05). CONCLUSION Decompressive craniectomy combined with temporal pole resection has a better effect in the treatment of patients with massive cerebral infarction. It has good decompression effect, the postoperative intracranial pressure is well controlled, and significantly reduced the mortality. So it has better clinical application value.
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Affiliation(s)
- Wenchao Lu
- Department of Neurosurgery, the Xi'an Daxing Hospital, No. 353 Laodong North Road, Xi'an, 710000, Shaanxi Province, China
| | - Dong Jia
- Department of Neurosurgery, the Xi'an Daxing Hospital, No. 353 Laodong North Road, Xi'an, 710000, Shaanxi Province, China
| | - Yanchang Qin
- Department of Neurosurgery, the Xi'an Daxing Hospital, No. 353 Laodong North Road, Xi'an, 710000, Shaanxi Province, China.
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18
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Sepponen R, Saviluoto A, Jäntti H, Harve-Rytsälä H, Lääperi M, Nurmi J. Validation of Score to Detect Intracranial Lesions in Unconscious Patients in Prehospital Setting. J Stroke Cerebrovasc Dis 2022; 31:106319. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/09/2022] [Indexed: 11/30/2022] Open
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19
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Sadeh M, Patel S, Souter J, Chiu R, Ansari D, Atwal GS. Clinical and radiographic risk indicators for decompressive hemicraniectomy in patients with ischemic stroke: an institutional and national analysis. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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20
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Kim JG, Ko MA, Lee HB, Jeon SB. Magnetic Resonance Imaging in Neurocritically Ill Patients: Who Fails and How? J Patient Saf 2021; 17:e1327-e1331. [PMID: 29629931 DOI: 10.1097/pts.0000000000000483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Performing magnetic resonance imaging (MRI) in neurocritically ill patients is challenging because it often requires sedation and withholding care in the neurological intensive care unit. This study investigated the incidence of and reasons for failed or complicated MRI (MRI-FC) in such patients. METHODS A consecutive series of 218 neurocritically ill patients who underwent brain MRI were retrospectively evaluated. Failed or complicated MRI included failure to obtain all ordered sequences, unscheduled sedative administration, decrease in oxygen saturation to less than 90%, hypotension (≥40-mm Hg decrease and/or use of inotropic agents), and cardiac or respiratory arrest. RESULTS Failed or complicated MRI occurred in 66 patients (30.3%) and included failure to obtain MRI sequences (n = 13), unscheduled use of sedatives (n = 62), oxygen desaturation (n = 9), and hypotension (n = 6). Cardiac or respiratory arrest did not occur. Use of sedative agents while in intensive care (P < 0.01), high Acute Physiology and Chronic Health Evaluation II score (P = 0.031), and low Glasgow Coma Scale score on admission (P = 0.047) were associated with MRI-FC. Scan times were longer (P = 0.004) and Glasgow Coma Scale (P < 0.001) and Richmond Agitation Sedation Scale (P = 0.003) scores were lower (P = 0.004) after imaging in patients with MRI-FC. Previous use of sedative agents was independently associated with MRI-FC (adjusted odds ratio = 3.57, 95% confidence interval = 1.78 to 7.24, P < 0.001). CONCLUSIONS Failed or complicated MRI was common and was associated with the use of sedative agents, severity of illness, and lower level of consciousness. Studies to ensure effective and safe performance of MRI in neurocritically ill patients are needed.
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Affiliation(s)
- Joong-Goo Kim
- From the Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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21
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Ultrasound of Optic Nerve Sheath Diameter and Stroke Outcomes. Crit Care Explor 2021; 3:e0565. [PMID: 34841250 PMCID: PMC8613366 DOI: 10.1097/cce.0000000000000565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. We aimed at utilizing ocular ultrasound to determine its utility in predicting outcomes among stroke patients.
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Zeng M, Zhou H, He Y, Du H, Yin J, Hou Y, Zhu J, Zhang Y, Shao C, Yang J, Wan H. Danhong injection enhances the therapeutic effect of mannitol on hemispheric ischemic stroke by ameliorating blood-brain barrier disruption. Biomed Pharmacother 2021; 142:112048. [PMID: 34435588 DOI: 10.1016/j.biopha.2021.112048] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 01/01/2023] Open
Abstract
Mannitol, a representative of hyperosmolar therapy, is indispensable for the treatment of malignant cerebral infarction, but its therapeutic effect is limited by its exacerbation of blood-brain barrier (BBB) disruption. This study was to explore whether Danhong injection (DHI), a standardized product extracted from Salvia miltiorrhiza Bunge and Carthamus tinctorius L., inhibits the destructive effect of mannitol on BBB and thus enhancing the treatment of hemispheric ischemic stroke. SD rats were subjected to pMCAO followed by intravenous bolus injections of mannitol with/without DHI intervention. Neurological deficit score, brain edema, infarct volume at 24 h after MCAO and histopathology, microvascular ultrastructure, immunohistochemistry and immunofluorescence staining of endothelial cell junctions, energy metabolism in the ischemic penumbra were assessed. Intravenous mannitol after MCAO resulted in a decrease in 24 h mortality and cerebral edema, whereas no significant benefit on neurological deficits, infarct volume and microvascular ultrastructure. Moreover, mannitol led to the loss of endothelial integrity, manifested by the decreased expression of occludin, junctional adhesion molecule-1 (JAM-1) and zonula occluden-1 (ZO-1) and the discontinuity of occludin staining around the periphery of endothelial cells. Meanwhile, after mannitol treatment, energy-dependent vimentin and F-actin, ATP content, and ATP5D expression were down-regulated, while MMP2 and MMP9 expression increased in the ischemic penumbra. All the insults after mannitol treatment were attenuated by addition of intravenous DHI. The results suggest DHI as a potential remedy to attenuate mannitol-related BBB disruption, and the potential of DHI to upregulate energy metabolism and inhibit the activity of MMPs is likely attributable to its effects observed.
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Affiliation(s)
- Miaolin Zeng
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Huifen Zhou
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yu He
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Haixia Du
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Junjun Yin
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yongchun Hou
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Jiaqi Zhu
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yangyang Zhang
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Chongyu Shao
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Jiehong Yang
- Zhejiang Chinese Medical University, Hangzhou 310053, China.
| | - Haitong Wan
- Zhejiang Chinese Medical University, Hangzhou 310053, China.
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Park C, Charalambous LT, Yang Z, Adil SM, Hodges SE, Lee HJ, Verbick LZ, McCabe AR, Lad SP. Inpatient mortality and healthcare resource utilization of nontraumatic intracerebral hemorrhage complications in the US. J Neurosurg 2021; 135:1081-1090. [PMID: 33482635 DOI: 10.3171/2020.8.jns201839] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nontraumatic, primary intracerebral hemorrhage (ICH) accounts for 2 million strokes worldwide annually and has a 1-year survival rate of 50%. Recent studies examining functional outcomes from ICH evacuation have been performed, but limited work has been done quantifying the incidence of subsequent complications and their healthcare economic impact. The purpose of this study was to quantify the incidence and healthcare resource utilization (HCRU) for major complications that can arise from ICH. METHODS The IBM MarketScan Research databases were used to retrospectively identify patients with ICH from 2010 to 2015. Complications examined included cerebral edema, hydrocephalus, venous thromboembolic events (VTEs), pneumonia, urinary tract infections (UTIs), and seizures. For each complication, inpatient mortality and HCRU were assessed. RESULTS Of 25,322 adult patients included, 10,619 (42%) developed complications during the initial admission of ICH: 22% had cerebral edema, 11% hydrocephalus, 10% pneumonia, 6% UTIs, 5% seizures, and 5% VTEs. The inpatient mortality rates at 7 and 30 days for each complication of ICH ranked from highest to lowest were hydrocephalus (24% and 32%), cerebral edema (15% and 20%), pneumonia (8% and 18%), seizure (7% and 13%), VTE (4% and 11%), and UTI (4% and 8%). Hydrocephalus had the highest total cost (median $92,776, IQR $39,308-$180,716) at 7 days post-ICH diagnosis and the highest cumulative total cost (median $170,839, IQR $91,462-$330,673) at 1 year post-ICH diagnosis. CONCLUSIONS This study characterizes one of the largest cohorts of patients with nontraumatic ICH in the US. More than 42% of the patients with ICH developed complications during initial admission, which resulted in high inpatient mortality and considerable HCRU.
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Affiliation(s)
| | | | - Zidanyue Yang
- 2Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina; and
| | | | | | - Hui-Jie Lee
- 2Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina; and
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Liu C, Song JX, Guo ZB, Chen LM, Zhao CH, Zi WJ, Yang QW. Prognostic Structural Neural Markers of MRI in Response to Mechanical Thrombectomy for Basilar Artery Occlusion. Front Neurol 2021; 12:593914. [PMID: 34177752 PMCID: PMC8220209 DOI: 10.3389/fneur.2021.593914] [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: 08/12/2020] [Accepted: 04/19/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Mechanical thrombectomy (MT) has been an effective first-line therapeutic strategy for ischemic stroke. With impairment characteristics separating it from anterior circulation stroke, we aimed to explore prognostic structural neural markers for basilar artery occlusion (BAO) after MT. Methods: Fifty-four BAO patients with multi-modal magnetic resonance imaging at admission from the multicenter real-world designed BASILAR research were enrolled in this study. Features including volumes for cortical structures and subcortical regions, locations and volumes of infarctions, and white matter hyperintensity (WMH) volumes were recorded from all individuals. The impact features were identified using ANCOVA and logistic analysis. Another cohort (n = 21) was further recruited to verify the prognostic roles of screened prognostic structures. Results: For the primary clinical outcome, decreased brainstem volume and total infarction volumes from mesencephalon and midbrain were significantly related to reduced 90-day modified Rankin score (mRS) after MT treatment. WMH volume, WMH grade, average cortex thickness, white matter volume, and gray matter volume did not exhibit a remarkable relationship with the prognosis of BAO. The increased left caudate volume was obviously associated with early symptomatic recovery after MT. The prognostic role of the ratio of pons and midbrain infarct volume in brainstem was further confirmed in another cohort with area under the curve (AUC) = 0.77. Conclusions: This study was the first to provide comprehensive structural markers for the prognostic evaluation of BAO. The fully automatic and semiautomatic segmentation approaches in our study supported that the proportion of mesencephalon and midbrain infarct volume in brainstem was a crucial prognostic structural neural marker for BAO.
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Affiliation(s)
- Chang Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jia-Xin Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhang-Bao Guo
- Department of Neurology, Wuhan No. 1 Hospital, Chongqing, China
| | - Lu-Ming Chen
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chen-Hao Zhao
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wen-Jie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qing-Wu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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25
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Naidu PB, Vivek V, Shareef MH, tilak S, Ganesh K. Decompressive hemicraniectomy in malignant MCA infarct in a tertiary centre. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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26
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Chen SY, Thompson-Leduc P, Sawyer RN, Fakih I, Cheung HC, Macheca M, Kirson NY, Torbey M. Outcomes and resource use of patients with large hemispheric infarction and cerebral edema: analysis of real-world data. Curr Med Res Opin 2021; 37:781-788. [PMID: 33685308 DOI: 10.1080/03007995.2021.1900090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Large hemispheric infarction (LHI) is associated with a high likelihood of the evolution of life-threatening edema. Few studies have assessed real-world clinical outcomes and management strategies among patients with LHI. The objective of this study was to describe the management, in-hospital outcomes, and direct healthcare resource burden of patients with LHI, as well as those of patients with subsequent cerebral edema. METHODS This observational, retrospective cohort study analyzed de-identified data from US adult patients using the IBM MarketScan Hospital Drug Database (Q4-2015 to Q4-2017). Patients were included in the "Possible LHI" or the "Other Ischemic Strokes" cohorts using ICD-10 diagnosis codes. Patients with possible LHI were further categorized into "LHI with Edema" and "LHI without Edema" subgroups using diagnosis and procedure codes. Select clinical and economic outcomes were compared between cohorts and subgroups using multivariable regressions. RESULTS Of 79,201 eligible encounters with ischemic strokes, 11,772 unique patients were assigned to the Possible LHI cohort while 67,429 were assigned to the Other Ischemic Strokes cohort. Among patients with possible LHI, 869 (7%) were assigned to the LHI with Edema subgroup and 10,903 (93%) were assigned to the LHI without Edema subgroup. Patients in the Possible LHI cohort had longer hospital stays (mean difference [MD] [95%CI] = 2.6 [2.4;2.8] days), higher total facility charges (MD [95%CI] = $28,656 [26,794;30,524]), and higher odds of death (odds ratio [95%CI] = 2.2 [2.0;2.4]) than the Other Ischemic Strokes cohort. Among patients with possible LHI, the incremental clinical and resource burden was further exacerbated in the subgroup of patients with edema (hospital days: MD [95%CI] = 5.0 [3.9;6.2] days; total facility charges: MD [95%CI] = $59,585 [50,816;67,583]; mortality: odds ratio [95%CI] = 10.3 [8.5;12.4]). CONCLUSIONS Among patients with ischemic strokes, LHI was associated with increased clinical management and direct healthcare resource burden in real-world hospital settings. The burden was substantially increased among patients who developed cerebral edema.
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Affiliation(s)
| | | | - Robert N Sawyer
- Department of Neurology, University at Buffalo, Buffalo, NY, USA
| | | | | | | | | | - Michel Torbey
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
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Musick S, Alberico A. Neurologic Assessment of the Neurocritical Care Patient. Front Neurol 2021; 12:588989. [PMID: 33828517 PMCID: PMC8019734 DOI: 10.3389/fneur.2021.588989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/02/2021] [Indexed: 11/30/2022] Open
Abstract
Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.
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Affiliation(s)
- Shane Musick
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
| | - Anthony Alberico
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
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Moustafa H, Schoene D, Altarsha E, Rahmig J, Schneider H, Pallesen LP, Prakapenia A, Siepmann T, Barlinn J, Passauer J, Reichmann H, Puetz V, Barlinn K. Acute kidney injury in patients with malignant middle cerebral artery infarction undergoing hyperosmolar therapy with mannitol. J Crit Care 2021; 64:22-28. [PMID: 33770572 DOI: 10.1016/j.jcrc.2021.02.007] [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: 12/26/2020] [Revised: 01/28/2021] [Accepted: 02/19/2021] [Indexed: 12/09/2022]
Abstract
PURPOSE To assess the kidney safety profile of mannitol in patients with malignant middle cerebral artery (MCA) infarction. MATERIAL AND METHODS We studied consecutive patients with malignant MCA infarction (01/2008-01/2018). Malignant MCA infarction was defined according to DESTINY criteria. We compared clinical endpoints including acute kidney injury (AKI; according to Kidney Disease: Improving Global Outcomes [KDIGO]) and dialysis between patients with and without mannitol. Multivariable model was built to explore predictor variables of AKI and in-hospital death. RESULTS Overall, 219 patients with malignant MCA infarction were included. Mannitol was administered in 93/219 (42.5%) patients with an average dosage of 650 g (250-950 g). Patients treated with mannitol more frequently suffered from AKI (39.8% vs. 11.9%; p < 0.001) and required hemodialysis (7.5% vs. 0.8%; p = 0.01) than patients without mannitol. At discharge, more patients in the mannitol group had persistent AKI than control patients (23.7% vs. 6.4%, p < 0.001). In multivariable model, mannitol emerged as independent predictor of AKI (OR 5.02, 95%CI 2.36-10.69; p < 0.001). CONCLUSIONS Acute kidney injury appears to be a frequent complication of hyperosmolar therapy with mannitol in patients with malignant MCA infarction. Given the lack of evidence supporting effectiveness of mannitol in these patients, its routine use should be carefully considered.
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Affiliation(s)
- Haidar Moustafa
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Daniela Schoene
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Eyad Altarsha
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jan Rahmig
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany; Medical Faculty, Technische Universität Dresden, Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Alexandra Prakapenia
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jens Passauer
- Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Cong L, Ma W. Early neurological deterioration in cardiogenic cerebral embolism due to nonvalvular atrial fibrillation: Predisposing factors and clinical implications. Brain Behav 2021; 11:e01985. [PMID: 33277821 PMCID: PMC7882173 DOI: 10.1002/brb3.1985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The aim of the study was to investigate factors which may predispose patients to early neurological deterioration (END) and explore peripheral biomarkers for the prediction of END in cardiogenic cerebral embolism (CCE) patients. METHODS Patients diagnosed with CCE within 24 hr of onset between January 2017 and January 2019 were included in this study. END was defined as an increase of ≥2 on the National Institutes of Health Stroke Scale (NIHSS) or the emergence of new neurological symptoms within 3 days of admission. Binary logistic regression was used to investigate the factors associated with END. Receiver operating characteristic (ROC) curves were then generated to determine the predictive value of the potential biomarkers and the optimal cutoff values. RESULTS Of the 129 (male, 55.81%; mean age 71.85 ± 11.99 years) CCE patients, 55 patients with END were identified. Hemorrhage transformation (HT), coronary heart disease (CHD), diastolic blood pressure, cystatin C levels, NIHSS score, and platelet-to-lymphocyte ratio (PLR) at admission were independently associated with END. A peripheral cystatin C level ≥ 1.41 mg/L and a PLR ≥ 132.97 were predictive factors for END in CCE patients. The lymphocyte-to-monocyte ratio (LMR) was negatively independently associated with HT, and LMR < 2.31 may predict the occurrence of HT in patients with CCE. CONCLUSIONS Of the potential predisposing factors considered, increased cystatin C and PLR were associated with END within 3 days of CCE, and a decreased LMR may have predictive value for HT in CCE patients.
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Affiliation(s)
- Lin Cong
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weining Ma
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
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Li G, Zhang B, Zhang M, Liu Q, Luo J, Liao Q, Tan M, Bai Z, Xu J, Sun J, Chen M. A non-invasive real-time monitoring system for cytotoxic brain edema in post ischemic stroke based on near-field coupling. Technol Health Care 2021; 29:963-978. [PMID: 33427707 DOI: 10.3233/thc-202685] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND As a common secondary pathophysiological process in postischemic stroke (IS), cytotoxic brain edema (CBE) is an independent factor leading to poor prognosis of patients. Near-field coupling (NFC) technology has some advantages such as non-invasive, non-contact, and unimpeded penetration of the skull. In theory, it can reflect the difference between normal and edema tissues through the near-field coupling phase shift (NFCPS) in the electromagnetic wave transmission trait. METHODS Combining NFC detection principle and computer programming, we established a high-performance real-time monitoring system with functions such as automatic setting of measurement parameters, data acquisition, real-time filtering and dynamic waveform display. To investigate the feasibility of this system to detect CBE, a saline simulation experiment and a 24-hour real-time monitoring experiment after middle cerebral artery occlusion (MCAO) in rats were carried out. RESULTS The results of the saline simulation experiment showed that the change of NFCPS was proportional to the increase of the simulated edema solution, and the variation range of NFCPS was more than 9∘ after 5 ml injection. In the 24-hour monitoring after MCAO, the NFCPS of the experimental group showed an overall downward trend over time an average change of -17.7868 ± 1.6325∘ and the change rate gradually decreased. The 24-hour NFCPS in the control group fluctuates slightly around the initial value, which has no obvious upward or downward trend. CONCLUSION The intragroup and intergroup difference statistical analysis shows that NFCPS can effectively distinguish different intracranial pathophysiological states after IS. This work provides sufficient evidence and a technical basis for using NFCPS to monitor CBE in the future.
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Affiliation(s)
- Gen Li
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Bo Zhang
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Maoting Zhang
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Qi Liu
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Jie Luo
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Qi Liao
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Mei Tan
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Zelin Bai
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Jia Xu
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Jian Sun
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Mingsheng Chen
- College of Biomedical Engineering, Army Medical University, Chongqing, China
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Lee SJ, Choi MH, Lee SE, Park JH, Park B, Lee JS, Hong JM. Optic nerve sheath diameter change in prediction of malignant cerebral edema in ischemic stroke: an observational study. BMC Neurol 2020; 20:354. [PMID: 32962645 PMCID: PMC7510108 DOI: 10.1186/s12883-020-01931-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 09/14/2020] [Indexed: 12/28/2022] Open
Abstract
Background In acute large anterior circulation infarct patients with large core volume, we evaluated the role of optic nerve sheath diameter (ONSD) change rates in prediction of malignant progression. Methods We performed a retrospective observational study including patients with anterior circulation acute ischemic stroke with large ischemic cores from January 2010 to October 2017. Primary outcome was defined as undergoing decompressive surgery or death due to severe cerebral edema, and termed malignant progression. Patients were divided into malignant progressors and nonprogressors. Malignant progression was divided into early progression that occurred before D1 CT, and late progression that occurred afterwards. Retrospective analysis of changes in mean ONSD/eyeball transverse diameter (ETD) ratio, and midline shifting (MLS) were evaluated on serial computed tomography (CT). Through analysis of CT at baseline, postprocedure, and at D1, the predictive ability of time based change in ONSD/ETD ratio in predicting malignant progression was evaluated. Results A total of 58 patients were included. Nineteen (32.8%) were classified as malignant; 12 early, and 7 late progressions. In analysis of CTpostprocedure, A 1 mm/hr. rate of change in MLS during the CTbaseline-CTpostprocedure time phase lead to a 6.7 fold increased odds of early malignant progression (p < 0.05). For ONSD/ETD, 1%/hr. change lead to a 1.6 fold increased odds, but this association was trending (p = 0.249). In the CTD1, 1%/day change of ONSD/ETD in the CTbaseline-CTD1 time phase lead to a 1.4 fold increased odds of late malignant progression (p = 0.021) while 1 mm/day rate of change in MLS lead to a 1.5 fold increased odds (p = 0.014). Conclusions The rate of ONSD/ETD changes compared to baseline at D1 CT can be a predictor of late malignant progression along with MLS. ONSD/ETD change rates evaluated at postprocedure did not predict early malignant progression.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Mun Hee Choi
- Department of Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Sung Eun Lee
- Department of Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Ji Hyun Park
- Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon, Republic of Korea
| | - Bumhee Park
- Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon, Republic of Korea.,Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
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The Clinical Usefulness of Targeted Temperature Management in Acute Ischemic Stroke with Malignant Trait After Endovascular Thrombectomy. Neurocrit Care 2020; 34:990-999. [PMID: 32812197 DOI: 10.1007/s12028-020-01069-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/27/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND/OBJECTIVE Targeted temperature management (TTM) may be more beneficial after endovascular treatment (EVT) in patients with a large ischemic core. Therefore, we assessed the usefulness of TTM for such patients from a multicenter endovascular registry. METHODS Anterior circulation stroke patients who underwent endovascular recanalization were included; acute ischemic stroke with malignant traits was designated as (1) baseline Alberta Stroke Program Early CT Score (ASPECTS) below 6 and (2) diffusion-weighted imaging (DWI) lesion volume measurement (> 82 ml) or National Institutes of Health Stroke Scale score > 20 and item Ia > 0. TTM (34.5 °C) was maintained for at least 48 h. RESULTS We evaluated baseline demographics, risk factors, EVT parameters, and clinical outcomes between the TTM and non-TTM groups. Among the 548 patients, the TTM group (n = 91) significantly had a lower baseline ASPECTS (p < 0.001) and a higher DWI volume (p < 0.001) than the non-TTM group (n = 457). TTM group had a lower prevalence of favorable outcome (0-2 of modified Rankin Scale at 3 months; p = 0.008) than the non-TTM group. In a subgroup analysis of malignant trait patients (n = 80), TTM patients (n = 28) had more favorable outcome (32.1% vs. 7.7% p = 0.009) and less hemorrhagic transformation (none vs. any hemorrhage, p = 0.007) than non-TTM patients (n = 52). After adjusting for potential outcome predictors, TTM (odds ratio [OR] 4.63; confidence interval [CI] 1.20-17.89; p = 0.026) and hypertension (OR 0.18; CI 0.04-0.74; p = 0.018) were found to be independent determinants. CONCLUSIONS Our data suggest that TTM attenuates impending hemorrhagic transformation and leads to favorable clinical outcomes in EVT patients with malignant trait.
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Pedicelli A, Valente I, Pilato F, Distefano M, Colosimo C. Stroke priorities during COVID-19 outbreak: acting both fast and safe. J Stroke Cerebrovasc Dis 2020; 29:104922. [PMID: 32417235 PMCID: PMC7200390 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104922] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 12/13/2022] Open
Abstract
While the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) spreads all over the world, the healthcare systems are facing the dramatic challenge of simultaneously fight against the outbreak and life-threating emergencies. In this biological setting, emergency departments and neurovascular teams are exposed to high risk of infection and should therefore be prepared to deal with neurological emergencies safely. The purpose of this article is to analyze the current evidence on COVID-19 in the context of acute ischemic stroke and to describe the model of behavior we are putting into action to maintain the stroke pathway both rapid for the patient and safe for the healthcare professionals. We reserve a specific focus on personal protection equipment, dress code and healthcare professional behavior.
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Affiliation(s)
- Alessandro Pedicelli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Roma, Italia.
| | - Iacopo Valente
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Roma, Italia.
| | - Fabio Pilato
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di scienze dell'invecchiamento, neurologiche ortopediche e della testa-collo, Area Neuroscienze, UOC Neurologia, 00168 Roma, Italia.
| | - Marisa Distefano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di scienze dell'invecchiamento, neurologiche ortopediche e della testa-collo, Area Neuroscienze, UOC Neurologia, 00168 Roma, Italia.
| | - Cesare Colosimo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Roma, Italia; Università Cattolica del Sacro Cuore, Roma, Italia.
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Kim YO, Chung CR, Park CM, Suh GY, Ryu JA. Severe pain-related adverse events of percutaneous dilatational tracheostomy performed by a neurointensivist compared with conventional surgical tracheostomy in neurocritically ill patients. BMC Neurol 2020; 20:223. [PMID: 32493239 PMCID: PMC7267757 DOI: 10.1186/s12883-020-01809-x] [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: 11/13/2019] [Accepted: 05/27/2020] [Indexed: 11/22/2022] Open
Abstract
Background We evaluated severe pain-related adverse events (SAE) during the percutaneous dilatational tracheostomy (PDT) procedure performed by a neurointensivist and compared the outcomes with that of conventional surgical tracheostomy in neurocritically ill patients. Methods This was a retrospective and observational study of adult patients who were admitted to the neurosurgical intensive care unit between January 2014 and March 2018 and underwent tracheostomy. In this study, primary endpoints were incidence of SAE: cardiac arrest, arrhythmias, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. The secondary endpoint was procedure-induced complications. Results A total of 156 patients underwent tracheostomy during the study. Elective surgery of brain tumors (34.0%) and intracranial hemorrhage (20.5%) were the most common reasons for admission. The most common reasons for tracheostomy were difficult ventilator weaning or prolonged intubation (42.9%) and sedative reduction (23.7%). Tachycardia (30.1%) and hypertension (30.1%) were the most common SAE. Incidence of SAE was more common in conventional tracheostomy compared to PDT (67.1% vs. 42.3%, P = 0.002). The total duration of SAE (19.8 ± 23.0 min vs. 3.4 ± 5.3 min, P < 0.001) and procedural time (42.2 ± 21.8 min vs. 17.7 ± 9.2 min, P < 0.001) were longer in conventional tracheostomy compared to PDT. Multivariable adjustment revealed that only PDT by a neurointensivist significantly reduced the incidence of SAE by one third (adjusted odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.187–0.691). In addition, PDT by a neurointensivist deceased the duration of SAE by 8.64 min (β: -8.64, 95% CI: − 15.070 – -2.205, P = 0.009) and prolonging the procedure time by every one minute significantly increased the duration of SAE by 6.38 min (β: 6.38, 95% CI: 0.166–0.470, P < 0.001). Procedure-induced complications were more common in conventional tracheostomy compared to PDT (23.5% vs. 11.3%, P = 0.047). Conclusions This retrospective and exploratory study of our single-center limited cohort of tracheostomy patients revealed that decreased SAE may be associated with short procedural time during the PDT procedure performed by a neurointensivist. It is proposed that PDT by a neurointensivist may be safe and feasible in neurocritically ill patients.
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Affiliation(s)
- Yong Oh Kim
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. .,Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Newly developed stroke in patients admitted to non-neurological intensive care units. J Neurol 2020; 267:2961-2970. [PMID: 32488294 PMCID: PMC7264485 DOI: 10.1007/s00415-020-09955-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Little is known about newly developed stroke in patients admitted to the intensive care unit (ICU). OBJECTIVE This study aimed to investigate characteristics and outcomes of newly developed stroke in patients admitted to the non-neurological intensive care units (ICU-onset stroke, IOS). METHODS A consecutive series of adult patients who were admitted to the non-neurological ICU were included in this study. We compared neurological profiles, risk factors, and mortality rates between patients with IOS and those without IOS. RESULTS Of 18,604 patients admitted to the ICU for non-neurological illness, 218 (1.2%) developed stroke (ischemic, n = 182; hemorrhagic, n = 36). The most common neurological presentation was altered mental status (n = 149), followed by hemiparesis (n = 55), and seizures (n = 28). The most common etiology of IOS was cardioembolism (50% [91/182]) for ischemic IOS and coagulopathy (67% [24/36]) for hemorrhagic IOS. In multivariable analysis, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (adjusted odds ratio [AOR] = 1.04, 95% CI = 1.03-1.06, P < 0.001), prothrombin time (AOR = 0.99, 95% CI = 0.98-0.99, P = 0.013), cardiovascular surgery (AOR = 1.84, 95% CI = 1.34-2.50, P < 0.001), mechanical ventilation (AOR = 6.75, 95% CI = 4.87-9.45, P < 0.001), and extracorporeal membrane oxygenation (AOR = 2.77, 95% CI = 1.62-4.55, P < 0.001) were related to the development of IOS. Stroke was associated with increased 3-month mortality after hospital discharge (AOR, 2.20; 95% CI, 1.58-3.05; P < 0.001), after adjustment for APACHE II and comorbidities. CONCLUSIONS Patients who developed IOS had characteristics of initial critical illness and managements performed in the ICU as well as neurological presentations. The occurrence of IOS was related to high morbidity and mortality.
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Spellicy SE, Kaiser EE, Bowler MM, Jurgielewicz BJ, Webb RL, West FD, Stice SL. Neural Stem Cell Extracellular Vesicles Disrupt Midline Shift Predictive Outcomes in Porcine Ischemic Stroke Model. Transl Stroke Res 2019; 11:776-788. [PMID: 31811639 PMCID: PMC7340639 DOI: 10.1007/s12975-019-00753-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 12/11/2022]
Abstract
Magnetic resonance imaging (MRI) is a clinically relevant non-invasive imaging tool commonly utilized to assess stroke progression in real time. This study investigated the utility of MRI as a predictive measure of clinical and functional outcomes when a stroke intervention is withheld or provided, in order to identify biomarkers for stroke functional outcome under these conditions. Fifteen MRI and ninety functional parameters were measured in a middle cerebral artery occlusion (MCAO) porcine ischemic stroke model. Multiparametric analysis of correlations between MRI measurements and functional outcome was conducted. Acute axial and coronal midline shift (MLS) at 24 h post-stroke were associated with decreased survival and recovery measured by modified Rankin scale (mRS) and were significantly correlated with 52 measured acute (day 1 post) and chronic (day 84 post) gait and behavior impairments in non-treated stroked animals. These results suggest that MLS may be an important non-invasive biomarker that can be used to predict patient outcomes and prognosis as well as guide therapeutic intervention and rehabilitation in non-treated animals and potentially human patients that do not receive interventional treatments. Neural stem cell–derived extracellular vesicle (NSC EV) was a disruptive therapy because NSC EV administration post-stroke disrupted MLS correlations observed in non-treated stroked animals. MLS was not associated with survival and functional outcomes in NSC EV–treated animals. In contrast to untreated animals, NSC EVs improved stroked animal outcomes regardless of MLS severity.
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Affiliation(s)
- Samantha E Spellicy
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, GA, 30602, USA
| | - Erin E Kaiser
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, GA, 30602, USA
| | - Michael M Bowler
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA
| | - Brian J Jurgielewicz
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, GA, 30602, USA
| | | | - Franklin D West
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, GA, 30602, USA
| | - Steven L Stice
- Regenerative Bioscience Center, University of Georgia, Athens, GA, 30602, USA.
- Department of Animal and Dairy Science, University of Georgia, Athens, GA, 30602, USA.
- ArunA Biomedical, Athens, GA, 30602, USA.
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Kotfis K, Bott-Olejnik M, Szylińska A, Listewnik M, Rotter I. Characteristics, Risk Factors And Outcome Of Early-Onset Delirium In Elderly Patients With First Ever Acute Ischemic Stroke - A Prospective Observational Cohort Study. Clin Interv Aging 2019; 14:1771-1782. [PMID: 31695347 PMCID: PMC6814355 DOI: 10.2147/cia.s227755] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 09/20/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction Post-stroke delirium is a common clinical problem, occurring in 10% to 48% of patients. It has been associated with longer hospitalization times, increased mortality and worse functional outcome. In early phase of stroke, it may be regarded as particularly difficult to differentiate from other neurological symptoms. For practical purposes, there is a need to identify simple pre-operative laboratory parameters that may aid delirium diagnosis early after stroke. Our aim was to identify the incidence of early-onset (first 24 hrs) post-stroke delirium, its risk factors and outcomes (complications and mortality) in patients with first-ever acute ischemic stroke (AIS). Material and methods A retrospective analysis of a prospective observational study (NCT03944694) was performed. Patients were screened for delirium using CAM-ICU method. Clinical and laboratory data were collected, including baseline inflammatory parameters. Results Final analysis included 760 patients, 121 (15.9%) developed delirium. Patients with delirium were older (75.9±13.5 years, p<0.001). Most common complications in the delirium group were pulmonary (57.8% vs 21.4%, p<0.001), cardiac (38.8% vs 13.6%, p<0.001) and renal (13.2% vs 7.5%, p=0.038). Neutrophil-to-lymphocyte ratio (NLR) (6.71±9.65 vs 4.55±5.51, p<0.001), C-reactive protein level (32.59±65.94 vs 15.70±38.56, p<0.001) and troponin T level (72.59±180.15 vs 26.85±77.62, p<0.001) were higher in delirious patients and platelet-to white blood cell count ratio (PWR) (23.42±9.51 vs 27.13±10.58, p<0.001) was lower. Multivariable logistic regression showed that atrial fibrillation (OR 1.651, p=0.049), higher Rankin score on admission (OR 1.689, p<0.001), hemianopia (OR 2.422, p=0.003) and PWR <20.22 (OR 2.197, p=0.002) were independently associated with delirium. Kaplan–Meier curves indicated that mortality increased for patients with delirium at 3 months (p<0.001) and 1 year (p<0.001) after AIS. Conclusion Atrial fibrillation, higher Rankin score, hemianopia and lower PWR were independently associated with early onset delirium in patients with first ever AIS. This confirms that deprivation of senses and early generalized inflammatory response are critical for delirium development.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin 70-204, Poland
| | - Marta Bott-Olejnik
- Neurology Department of a Regional Specialist Hospital in Gryfice, Gryfice 72-300, Poland
| | - Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin 70-204, Poland
| | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin 70-204, Poland
| | - Iwona Rotter
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin 70-204, Poland
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Liu CH, Hsiao CT, Chang TY, Chang YJ, Kuo SH, Chang CW, Chen CJ, Chen CF, Cheng PL, Chin SC, Chiu TF, Hsu JL, Hsu PW, Lee TH, Liao CH, Lin CJ, Lin LH, Seak CJ, Sung PS, Yang TC, Wu YM. Brain computerized tomography reading in suspected acute ischemic stroke patients: what are essentials for medical students? BMC MEDICAL EDUCATION 2019; 19:359. [PMID: 31533703 PMCID: PMC6749686 DOI: 10.1186/s12909-019-1781-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 08/30/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Few systematic methods prioritize the image education in medical students (MS). We hope to develop a checklist of brain computerized tomography (CT) reading in patients with suspected acute ischemic stroke (AIS) for MS and primary care (PC) physicians. METHODS Our pilot group generated the items indicating specific structures or signs for the checklist of brain CT reading in suspected AIS patients for MS and PC physicians. These items were used in a modified web-based Delphi process using the online software "SurveyMonkey". In total 15 panelists including neurologists, neurosurgeons, neuroradiologists, and emergency department physicians participated in the modified Delphi process. Each panelist was encouraged to express feedback, agreement or disagreement on the inclusion of each item using a 9-point Likert scale. Items with median scores of 7-9 were included in our final checklist. RESULTS Fifty-two items were initially provided for the first round of the Delphi process. Of these, 35 achieved general agreement of being an essential item for the MS and PC physicians. The other 17 of the 52 items in this round and another two added items suggested by the panelists were further rated in the next round. Finally, 38 items were included in the essential checklist items of brain CT reading in suspected AIS patients for MS and PC physicians. CONCLUSIONS We established a reference regarding the essential items of brain CT reading in suspected AIS patients. We hope this helps to minimize malpractice and a delayed diagnosis, and to improve competency-based medical education for MS and PC physicians.
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Affiliation(s)
- Chi-Hung Liu
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Medical Education, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Ting Hsiao
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Medical Education, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Chang Gung Medical Education Research Centre, Taoyuan, Taiwan
| | - Ting-Yu Chang
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yeu-Jhy Chang
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Division of Medical Education, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Chang Gung Medical Education Research Centre, Taoyuan, Taiwan.
| | - Sheng-Han Kuo
- Department of Neurology, Columbia University, New York, USA
| | - Chun-Wei Chang
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Chi-Jen Chen
- Department of Radiology, Shuang-Ho Hospital, New Taipei City, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Fu Chen
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Liang Cheng
- Emergency Department, Dalin Tzu Chi Hospital, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shy-Chyi Chin
- Department of Medical Imaging and Intervention, Linkou Medical Center, Chang Gung Memorial Hospital, Chang-Gung University, Taoyuan, Taiwan
| | - Te-Fa Chiu
- Department of Emergency Medicine, China Medical University Hospital, School of Medicine, China Medical University, Taichung, Taiwan
| | - Jung-Lung Hsu
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Graduate Institute of Humanities in Medicine and Research Center for Brain and Consciousness, Taipei Medical University, Taipei, Taiwan
| | - Peng-Wei Hsu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Chih-Hsiang Liao
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Li-Han Lin
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chen-June Seak
- Department of Emergency Medicine, Linkou Medical Center, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University Taoyuan, Taoyuan City, Taiwan
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tao-Chieh Yang
- Department of Neurosurgery, School of Medicine, Chung Shan Medical University, Hospital, Chung Shan Medical University, Taichung, Taiwan
| | - Yi-Ming Wu
- Emergency Department, Dalin Tzu Chi Hospital, Chiayi, Taiwan
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Duan H, Huber M, Ding JN, Huber C, Geng X. Local endovascular infusion and hypothermia in stroke therapy: A systematic review. Brain Circ 2019; 5:68-73. [PMID: 31334359 PMCID: PMC6611196 DOI: 10.4103/bc.bc_9_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/03/2019] [Accepted: 05/16/2019] [Indexed: 01/01/2023] Open
Abstract
Ischemic stroke is a leading cause of death and disability worldwide, but there are no effective, widely applicable stroke therapies. Systemic hypothermia is an international mainstay of postcardiac arrest care, and the neuroprotective benefits of systemic hypothermia following cerebral ischemia have been proven in clinical trials, but logistical issues hinder clinical acceptance. As a novel solution to these logistical issues, the application of local endovascular infusion of cold saline directly to the infarct site using a microcatheter has been put forth. In small animal models, the procedure has shown incredible neuroprotective promise on the biochemical, structural, and functional levels, and preliminary trials in large animals and humans have been similarly encouraging. In addition, the procedure would be relatively cost-effective and widely applicable. The administration of local endovascular hypothermia in humans is relatively simple, as this is a normal part of endovascular intervention for neuroendovascular surgeons. Therefore, it is expected that this new therapy could easily be added to an angiography suite. However, the neuroprotective efficacy in humans has yet to be determined, which is an end goal of researchers in the field. Given the potentially massive benefits, ease of induction, and cost-effective nature, it is likely that local endovascular hypothermia will become an integral part of endovascular treatment following ischemic stroke. This review outlines relevant research, discusses neuroprotective mechanisms, and discusses possibilities for future directions.
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Affiliation(s)
- Honglian Duan
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Mitchell Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Jessie N Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Christian Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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Lee SJ, Lee KS, Lee JS, Choi MH, Lee SE, Hong JM. Primary neurocritical care involving therapeutic hypothermia for acute ischemic stroke patients with malignant infarct cores. JOURNAL OF NEUROCRITICAL CARE 2019. [DOI: 10.18700/jnc.190076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Donovan J, Figaji A, Imran D, Phu NH, Rohlwink U, Thwaites GE. The neurocritical care of tuberculous meningitis. Lancet Neurol 2019; 18:771-783. [PMID: 31109897 DOI: 10.1016/s1474-4422(19)30154-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 02/28/2019] [Accepted: 03/05/2019] [Indexed: 12/16/2022]
Abstract
Tuberculous meningitis is the most severe form of tuberculosis and often causes critical illness with high mortality. Two primary management objectives are reducing intracranial pressure, and optimising cerebral perfusion, while killing the bacteria and controlling intracerebral inflammation. However, the evidence base guiding the care of critically ill patients with tuberculous meningitis is poor and many patients do not have access to neurocritical care units. Invasive intracranial pressure monitoring is often unavailable and although new non-invasive monitoring techniques show promise, further evidence for their use is required. Optimal management regimens of neurological complications (eg, hydrocephalus and paradoxical reactions) and of hyponatraemia, which frequently accompanies tuberculous meningitis, remain to be elucidated. Advances in the field of tuberculous meningitis predominantly focus on diagnosis, inflammatory processes, and antituberculosis chemotherapy. However, clinical trials are required to provide robust evidence guiding the most effective supportive, therapeutic, and neurosurgical interventions for tuberculous meningitis that will improve morbidity and mortality.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Darma Imran
- Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Ursula Rohlwink
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Kim JG, Lee HB, Jeon SB. Combination of Dexmedetomidine and Ketamine for Magnetic Resonance Imaging Sedation. Front Neurol 2019; 10:416. [PMID: 31105637 PMCID: PMC6492498 DOI: 10.3389/fneur.2019.00416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/05/2019] [Indexed: 01/10/2023] Open
Abstract
Objectives: The use of dexmedetomidine and ketamine (DEX-KET) combination for magnetic resonance imaging (MRI) sedation has not been evaluated. We investigated the efficacy and safety of DEX-KET for sedation of patients undergoing MRI of the brain. Methods: This quasi-experimental study was conducted to compare the DEX-KET combination and midazolam for MRI sedation. We included 72 patients undergoing brain MRI following bolus injection of midazolam or DEX-KET. In August 1, 2016 a new MRI sedation protocol was implemented. After protocol implementation, bolus doses of DEX-KET were administered (DEX-KET group). Thirty-six patients from the MIDA group and 36 patients from the DEX-KET group underwent MRI sequences and were compared regarding the MRI scan time and sedation-related complications (desaturation, hypotension, cardiorespiratory arrest, and aspiration pneumonia). Results: All MRI sequences were completed for 30 patients (83.3%) from the MIDA group and for 33 patients (91.7%) from the DEX-KET group (P = 0.476). The median MRI scan time was 100.0 min (interquartile range, 87.0-111.5 min) in the MIDA group and 53.5 min (interquartile range, 45.0-60.5 min) in the DEX-KET group (P < 0.001). Complications occurred in 24 (66.7%) and 8 (22.2%) patients of the MIDA and DEX-KET group, respectively (P < 0.001). Conclusions: The efficacy of DEX-KET sedation was comparable to that of midazolam for MRI examination. DEX-KET was related to shorter scan time and lower occurrence of complications compared to midazolam.
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Affiliation(s)
- Joong-Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea.,Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Han-Bin Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Kozaci N, Avci M, Caliskan G, Yuksel S. Variability of optic nerve sheath diameter in acute ischemic stroke. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919842982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Stroke is the third leading cause of death and the first cause of disability in the world. It holds an important place in hospital admissions and health expenses in the industrialized world. Objective: The aim of the study was to evaluate the relationship between optic nerve sheath diameter and the findings of brain computerized tomography scans and brain diffusion-weighted imaging and investigate the variability of optic nerve sheath diameter measured by ultrasonography in acute ischemic stroke. Methods: Patients who had acute ischemic stroke were included in Group A. Healthy adults were included in Group B as the control group. In addition, according to computerized tomography scans and diffusion-weighted imaging findings, Group A was divided into three subgroups. Patients with normal computerized tomography and diffusion-weighted imaging were included in Group 1, patients with normal computerized tomography and ischemic area on diffusion-weighted imaging were included in Group 2, and patients with ischemic area on computerized tomography and diffusion-weighted imaging were included in Group 3. Results: A total of 100 patients were included in Group A and 100 healthy adults included in Group B. The optic nerve sheath diameter values of Groups A and B were 5.4 ± 0.6 and 4.2 ± 0.4 mm (p < 0.001), respectively. The optic nerve sheath diameter cutoff value for detection of acute ischemic stroke was determined as 4.7 mm. The sensitivity and specificity at this cutoff value were determined as 89% and 90%, respectively. According to computerized tomography scans and diffusion-weighted imaging findings, there were 18 patients in Group 1, 56 patients in Group 2, and 26 patients in Group 3. Time from onset of symptoms to presentation to emergency department was shortest in Group 1 (3.0 ± 1.8 h). The widest optic nerve sheath diameter was calculated in Group 3 (optic nerve sheath diameter: 5.7 ± 0.6 mm). Conclusion: This study demonstrates that the optic nerve sheath diameter increases in acute ischemic stroke and it increases earlier than computerized tomography and diffusion-weighted imaging alteration occur. Therefore, optic nerve sheath diameter can be applied to assist the diagnosis of acute ischemic stroke with other imaging techniques with equivocal/negative results and determination of appropriate treatment, especially in cases with normal computerized tomography scan and diffusion-weighted imaging.
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Affiliation(s)
- Nalan Kozaci
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Mustafa Avci
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Gulsum Caliskan
- Department of Emergency Medicine, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Serkan Yuksel
- Department of Radiology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
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Kim JM, Bae JH, Park KY, Lee WJ, Byun JS, Ahn SW, Shin HW, Han SH, Yoo IH. Incidence and mechanism of early neurological deterioration after endovascular thrombectomy. J Neurol 2019; 266:609-615. [DOI: 10.1007/s00415-018-09173-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/24/2018] [Accepted: 12/26/2018] [Indexed: 11/24/2022]
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Pallesen LP, Barlinn K, Puetz V. Role of Decompressive Craniectomy in Ischemic Stroke. Front Neurol 2019; 9:1119. [PMID: 30687210 PMCID: PMC6333741 DOI: 10.3389/fneur.2018.01119] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/06/2018] [Indexed: 12/12/2022] Open
Abstract
Ischemic stroke is one of the leading causes for death and disability worldwide. In patients with large space-occupying infarction, the subsequent edema complicated by transtentorial herniation poses a lethal threat. Especially in patients with malignant middle cerebral artery infarction, brain swelling secondary to the vessel occlusion is associated with high mortality. By decompressive craniectomy, a significant proportion of the skull is surgically removed, allowing the ischemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. Several studies have shown that decompressive craniectomy reduces the mortality rate in patients with malignant cerebral artery infarction. However, this is done for the cost of a higher proportion of patients who survive with severe disability. In this review, we will describe the clinical and radiological features of malignant middle cerebral artery infarction and the role of decompressive craniectomy and additional therapies in this condition. We will also discuss large cerebellar stroke and the possibilities of suboccipital craniectomy.
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Affiliation(s)
- Lars-Peder Pallesen
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
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Ko MA, Lee JH, Kim JG, Jeong S, Kang DW, Lim CM, Lee SA, Kim KK, Jeon SB. Effects of Appointing a Full-Time Neurointensivist to Run a Closed-Type Neurological Intensive Care Unit. J Clin Neurol 2019; 15:360-368. [PMID: 31286709 PMCID: PMC6620450 DOI: 10.3988/jcn.2019.15.3.360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/25/2019] [Accepted: 02/25/2019] [Indexed: 01/08/2023] Open
Abstract
Background and Purpose To investigate whether appointing a full-time neurointensivist to manage a closed-type neurological intensive care unit (NRICU) improves the quality of critical care and patient outcomes. Methods This study included patients admitted to the NRICU at a university hospital in Seoul, Korea. Two time periods were defined according to the presence of a neurointensivist in the preexisting open-type NRICU: the before and after periods. Hospital medical records were queried and compared between these two time periods, as were the biannual satisfaction survey results for the families of patients. Results Of the 15,210 patients in the neurology department, 2,199 were admitted to the NRICU (n=995 and 1,204 during the before and after periods, respectively; p<0.001). The length of stay was shorter during the after than during the before period in both the NRICU (3 vs. 4 days; p<0.001) and the hospital overall (12.5 vs. 14.0 days; p<0.001). Neurological consultations (2,070 vs. 3,097; p<0.001) and intrahospital transfers from general intensive care units to the NRICU (21 vs. 40; p=0.111) increased from the before to after the period. The mean satisfaction scores of the families of the patients also increased, from 78.3 to 89.7. In a Cox proportional hazards model, appointing a neurointensivist did not result in a statistically significant change in 6-month mortality (hazard ratio, 0.82; 95% confidence interval, 0.652–1.031; p=0.089). Conclusions Appointing a full-time neurointensivist to manage a closed-type NRICU had beneficial effects on quality indicators and patient outcomes.
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Affiliation(s)
- Myung Ah Ko
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Hwa Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joong Goo Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Neurology, Jeju National University Hospital, Jeju, Korea
| | - Suyeon Jeong
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ahm Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kwang Kuk Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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A comparison of anticonvulsant efficacy and action mechanism of Mannitol vs Phenytoin in adult rat neocortical slices. IBRO Rep 2018; 3:55-64. [PMID: 30135942 PMCID: PMC6084822 DOI: 10.1016/j.ibror.2017.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/21/2017] [Accepted: 09/06/2017] [Indexed: 11/23/2022] Open
Abstract
We show that, in adult rat neocortical slices, an anticonvulsant effect comparable to that of Phenytoin can be obtained through a Mannitol-induced increase in extracellular osmolarity of only 30 mOsm/L. The anticonvulsant action of extracellular hyperosmolarity has been known for decades but has not found a feasible therapeutic application, yet. A 30 mOsm/L increase in extracellular osmolarity is already utilized in neurocritical care though not as an anticonvulsant agent: the data suggest a possible effective anticonvulsant use, too, in this setting. We used multiple electrode arrays to characterize and compare the anticonvulsant mechanisms of Mannitol and Phenytoin. Phenytoin decreased the voltage, duration and spatial spread of rhythmic repetitive, ictal-like activity. In contrast, Mannitol did not significantly affect voltage, duration and spatial spread of rhythmic repetitive, ictal-like activity but rather it inhibited the rate of epileptiform discharges.
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Jeong WJ, Bang JS, Yum KS, Lee S, Chung I, Kwon OK, Oh CW, Kim BJ, Bae HJ, Han MK. Radiologic Measurement of Brain Swelling in Patients with Large Hemispheric Infarctions During Targeted Temperature Management. Ther Hypothermia Temp Manag 2018; 8:136-142. [PMID: 29447082 DOI: 10.1089/ther.2017.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Brain herniation is most often the result of severe brain swelling and can rapidly lead to death or brain death. We retrospectively identified radiologic indicators to evaluate the effects of targeted temperature management (TTM) on the extent of cerebral edema and determine the cutoff values that best predict TTM outcomes in patients with large hemispheric infarction. We retrospectively reviewed brain computed tomography (CT) scans of 21 patients with large hemispheric infarctions, who were treated with TTM. We excluded 4 patients whose CT scans were inadequate for evaluation, which left 17 patients. We divided the patients into success and failure groups. TTM failure was defined as death or the need for decompressive hemicraniectomy (DHC) after TTM. Infarction size was measured as the total restricted area in diffusion-weighted imaging that was performed on admission. CT scans were obtained on the first and second days after TTM initiation and then every 2 days. We measured septum pellucidum shifts (SPS) and pineal gland shifts (PGS) on CT scans. The median time from symptom onset to TTM initiation was 14.5 hours. Ten patients were successfully treated with TTM, six patients died, and one patient underwent a DHC. Initial infarction sizes were not significantly different between the success and failure groups (p = 0.529), but the SPS and PGS at 36-72 hours after TTM initiation were (mean SPS: 5.0 vs. 14.9 mm, p = 0.001; mean PGS: 2.3 vs. 7.9 mm, p = 0.001). The sensitivity and negative predictive value for TTM failure caused by cerebral edema (SPS ≥9.25 mm and PGS ≥3.70 mm) at 36-72 hours after TTM initiation were both 100%. The SPS and PGS on CT scans taken 36-72 hours after TTM initiation may help to estimate the effect of TTM on cerebral edema and guide further treatment.
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Affiliation(s)
- Won Joo Jeong
- 1 Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Jae Seung Bang
- 1 Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Kyu Sun Yum
- 2 Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Sangkil Lee
- 3 Department of Neurology, Chungbuck National University Hospital , Cheongju, South Korea
| | - Inyoung Chung
- 2 Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - O-Ki Kwon
- 1 Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Chang Wan Oh
- 1 Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Beom Joon Kim
- 2 Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Hee-Joon Bae
- 2 Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Moon-Ku Han
- 2 Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
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Isoflurane post-conditioning down-regulates expression of aquaporin 4 in rats with cerebral ischemia/reperfusion injury and is possibly related to bone morphogenetic protein 4/Smad1/5/8 signaling pathway. Biomed Pharmacother 2018; 97:429-438. [DOI: 10.1016/j.biopha.2017.10.082] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 10/14/2017] [Accepted: 10/16/2017] [Indexed: 01/25/2023] Open
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Yuan MZ, Li F, Fang Q, Wang W, Peng JJ, Qin DY, Wang XF, Liu GW. Research on the cause of death for severe stroke patients. J Clin Nurs 2017; 27:450-460. [PMID: 28677276 DOI: 10.1111/jocn.13954] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2017] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To explore the characteristics of mortality among severe stroke patients, analyse their causes of death and provide evidence for improving the survival rate of stroke patients. BACKGROUND Stroke is an important fatal and disabling disease that poses a large burden on its patients, and its high death rates have caused substantial concern to the World Health Organization. DESIGN A retrospective case-control study. METHODS A total of 188 patients who died of stroke in the neurological intensive care unit of the First Affiliated Hospital of Chongqing Medical University from January 2012-December 2015 were selected as cases. Additionally, 188 stroke survivors from the same neurological intensive care unit were randomly selected as paired cases. The clinical characteristics of the severe stroke patient deaths were analysed, and a univariate analysis was conducted to determine potential mortality risk factors. A logistic regression analysis was then conducted to determine the independent risk factors of mortality. RESULTS We investigated a total of 231 cases of death in neurological intensive care unit patients, 188 of whom died of stroke. Therefore, the death rate from stroke accounted for 81.3% of the total population, with ischaemic, haemorrhagic and mixed strokes accounting for 47.19%, 26.84% and 7.36% of the patients, respectively. The leading cause of death was central nervous system-related causes (central respiratory and circulatory failure, brain herniation), followed by multisystemic causes. The independent risk factors of death among the neurological intensive care unit patients were as follows: brain herniation (OR = 18.15), multiple organ failure (OR = 13.12), dyslipidemia (OR = 4.64), community-acquired lung infection (OR = 4.15), use of mechanical ventilation (OR = 3.37), hypoproteinemia (OR = 2.29), history of hypertension (OR = 2.03) and hospital-acquired pneumonia (OR = 1.75). CONCLUSIONS The most common cause of death in stroke patients was damage to the central nervous system. Independent risk factors were brain herniation, multiple organ failure, dyslipidemia, community-acquired lung infection, the use of mechanical ventilation, hypoproteinemia, a history of hypertension and hospital-acquired pneumonia. Clinicians should be aware of the presence and possible effects of these conditions. Early prevention, monitoring and intervention to modify controllable risk factors will improve patient prognosis. RELEVANCE TO CLINICAL PRACTICE Clinicians should be aware of the multiple independent risk factors of death and implement timely treatment measures to reduce the incidence of death in severe stroke patients.
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Affiliation(s)
- Mei-Zhen Yuan
- The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Feng Li
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Qin Fang
- The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Wei Wang
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jing-Jing Peng
- The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - De-Yu Qin
- The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xue-Feng Wang
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Guang-Wei Liu
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
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