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Schweingruber N, Bremer J, Wiehe A, Mader MMD, Mayer C, Woo MS, Kluge S, Grensemann J, Quandt F, Gempt J, Fischer M, Thomalla G, Gerloff C, Sauvigny J, Czorlich P. Early prediction of ventricular peritoneal shunt dependency in aneurysmal subarachnoid haemorrhage patients by recurrent neural network-based machine learning using routine intensive care unit data. J Clin Monit Comput 2024:10.1007/s10877-024-01151-4. [PMID: 38512361 DOI: 10.1007/s10877-024-01151-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/08/2024] [Indexed: 03/23/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) can lead to complications such as acute hydrocephalic congestion. Treatment of this acute condition often includes establishing an external ventricular drainage (EVD). However, chronic hydrocephalus develops in some patients, who then require placement of a permanent ventriculoperitoneal (VP) shunt. The aim of this study was to employ recurrent neural network (RNN)-based machine learning techniques to identify patients who require VP shunt placement at an early stage. This retrospective single-centre study included all patients who were diagnosed with aSAH and treated in the intensive care unit (ICU) between November 2010 and May 2020 (n = 602). More than 120 parameters were analysed, including routine neurocritical care data, vital signs and blood gas analyses. Various machine learning techniques, including RNNs and gradient boosting machines, were evaluated for their ability to predict VP shunt dependency. VP-shunt dependency could be predicted using an RNN after just one day of ICU stay, with an AUC-ROC of 0.77 (CI: 0.75-0.79). The accuracy of the prediction improved after four days of observation (Day 4: AUC-ROC 0.81, CI: 0.79-0.84). At that point, the accuracy of the prediction was 76% (CI: 75.98-83.09%), with a sensitivity of 85% (CI: 83-88%) and a specificity of 74% (CI: 71-78%). RNN-based machine learning has the potential to predict VP shunt dependency on Day 4 after ictus in aSAH patients using routine data collected in the ICU. The use of machine learning may allow early identification of patients with specific therapeutic needs and accelerate the execution of required procedures.
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Affiliation(s)
- Nils Schweingruber
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Jan Bremer
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Anton Wiehe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
- Department of Informatics, University of Hamburg, 22527, Hamburg, Germany
| | - Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Christina Mayer
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), Center for Molecular Neurobiology Hamburg (ZMNH), University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Marcel Seungsu Woo
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), Center for Molecular Neurobiology Hamburg (ZMNH), University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Fanny Quandt
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Jennifer Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Sauvigny J, Mader MMD, Freundlieb N, Gempt J, Westphal M, Zöllner C, Mende A, Czorlich P. Patient perception and satisfaction in awake burr hole trepanation under local anesthesia for evacuation of chronic subdural hematoma. Clin Neurol Neurosurg 2024; 236:108085. [PMID: 38134758 DOI: 10.1016/j.clineuro.2023.108085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023]
Abstract
Evacuation of chronic subdural hematoma (CSDH) will be one of the most common neurosurgical procedures in the future in the increasingly aging societies. Performing cranial surgery on awake patients may place a psychological burden on them. Aim of this study was to evaluate the psychological distress of patients during awake CSDH relief. Patients with awake evacuation of CSDH via burr hole trepanation were included in our monocentric prospective study. Patient perception and satisfaction were measured using standardized surveys 3-5 days and 6 months after surgery. Among other questionnaires, the Hospital Anxiety and Depression and the Impact of Event Scale, were used to quantify patients' stress. A total of 50 patients (mean age 72.9 years (range 51 - 92)) were included. During surgery, 28 patients reported pain (mean 4.1 (SD 3.3)). Postoperatively, 26 patients experienced pain (mean 2.7 (SD 2.6)). Patients' satisfaction with intraoperative communication was reported with a mean of 8.3 (SD 2.1). There was a significant negative correlation between intraoperatively perceived pain and satisfaction with intraoperative communication (p = 0.023). Good intraoperative communication during evacuation of CSDH in awake patients is associated with positive patient perception and correlates with pain reduction.
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Affiliation(s)
- Jennifer Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | - Nils Freundlieb
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Mende
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Pantel T, Neulen A, Mader MMD, Kurz E, Piffko A, Fassl V, Westphal M, Gempt J, Ringel F, Czorlich P. Impact of pre-hospital handling and initial time to cranial computed tomography on outcome in aneurysmal subarachnoid hemorrhage patients with out-of-hospital sudden cardiac arrest-a retrospective bi-centric study. Front Cardiovasc Med 2023; 10:1209939. [PMID: 37671140 PMCID: PMC10475531 DOI: 10.3389/fcvm.2023.1209939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/24/2023] [Indexed: 09/07/2023] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (SAH) presents occasionally with cardiac arrest (CA). The impact of pre-hospital and emergency room (ER) treatment on outcome remains unclear. Therefore, we investigated the impact of pre-hospital treatment, focusing on lay cardiopulmonary resuscitation (CPR), and ER handling on the outcome of SAH patients with out-of-hospital CA (OHCA). Methods In this bi-centric retrospective analysis, we reviewed SAH databases for OHCA and CPR from January 2011 to June 2021. Patients were analyzed for general clinical and epidemiological parameters. CPR data were obtained from ambulance reports and information on ER handling from the medical records. Data were correlated with patient survival at hospital discharge as a predefined outcome parameter. Results Of 1,120 patients with SAH, 45 (4.0%) were identified with OHCA and CPR, 38 of whom provided all required information and were included in this study. Time to resuscitation was significantly shorter with lay resuscitation (5.3 ± 5.2 min vs. 0.3 ± 1.2 min, p = 0.003). Nineteen patients were not initially scheduled for cranial computed tomography (CCT), resulting in a significantly longer time interval to first CCT (mean ± SD: 154 ± 217 min vs. 40 ± 23 min; p < 0.001). Overall survival to discharge was 31.6%. Pre-hospital lay CPR was not associated with higher survival (p = 0.632). However, we observed a shorter time to first CCT in surviving patients (p = 0.065). Conclusions OHCA in SAH patients is not uncommon. Besides high-quality CPR, time to diagnosis of SAH appears to play an important role. We therefore recommend considering CCT diagnostics as part of the diagnostic algorithm in patients with OHCA.
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Affiliation(s)
- Tobias Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | - Elena Kurz
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Verena Fassl
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Göttsche J, Knospe V, Sauvigny T, Schweingruber N, Grensemann J, Spitzer MS, Westphal M, Skevas C, Czorlich P. Terson Syndrome in Patients with Aneurysmal Subarachnoid Hemorrhage: A 10-Year Single-Center Experience. Neurocrit Care 2023; 39:155-161. [PMID: 36949361 PMCID: PMC10499731 DOI: 10.1007/s12028-023-01701-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/14/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Terson syndrome (TS), an intraocular hemorrhage associated with aneurysmal subarachnoid hemorrhage (aSAH), occurs in up to 46% of all patients with subarachnoid hemorrhage. Despite its high incidence, TS is underrepresented in the literature, and patients with aSAH are sometimes not systematically evaluated for the presence of TS in clinical practice. This work aims to raise awareness of TS, reevaluate previous scientific findings, describe risk factors associated with the occurrence of TS, and present our local diagnostic and treatment concept. METHODS All patients with aSAH treated at our institution between October 2010 and May 2020 were included in this retrospective study. The frequency of ophthalmological screening by indirect funduscopy, as well as the results, was investigated. In addition, the collection and statistical analysis of epidemiological and clinical data was performed using χ2, Kruskal-Wallis, and analysis of variance testing; multivariate regression; and receiver operating characteristic analysis. The significance level was set at p < 0.05. RESULTS A total of 617 patients were treated for aSAH in our institution. Of these, 367 patients (59.5%) were ophthalmologically examined for the presence of TS. The rate of TS in the examined patients was 21.3% (n = 78). Patients with TS had significantly higher Fisher and World Federation of Neurosurgical Societies (WFNS) scores (p < 0.0001). Regression analyses showed WFNS grade (p = 0.003) and the occurrence of seizures (p = 0.002) as independent predictors of TS, as did receiver operating characteristic analyses, which had a significant area under the curve of 0.66 for the combination of WFNS grade and seizures. For 12 (15.4%) patients, the TS had to be surgically treated by pars plana vitrectomy in a total of 14 eyes, which resulted in significant improvement of visual function in all patients: mean preoperative best-corrected visual acuity was 0.03 (± 0.08) versus 0.76 (± 0.21) postoperatively (p < 0.001). CONCLUSIONS TS is a common complication in patients with aSAH, affecting approximately one in five patients. A higher WFNS grade and the occurrence of seizures are associated with TS; therefore, screening for TS should be performed in these patients.
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Affiliation(s)
- Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Volker Knospe
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils Schweingruber
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin S Spitzer
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christos Skevas
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Wolf S, Mielke D, Barner C, Malinova V, Kerz T, Wostrack M, Czorlich P, Salih F, Engel DC, Ehlert A, Staykov D, Alturki AY, Sure U, Bardutzky J, Schroeder HWS, Schürer L, Beck J, Juratli TA, Fritsch M, Lemcke J, Pohrt A, Meyer B, Schwab S, Rohde V, Vajkoczy P. Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial. JAMA Neurol 2023; 80:833-842. [PMID: 37330974 PMCID: PMC10277935 DOI: 10.1001/jamaneurol.2023.1792] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/31/2023] [Indexed: 06/20/2023]
Abstract
Importance After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome. Objective To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage. Design, Setting, and Participants The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours. Intervention A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage. Main Outcomes and Measures Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage. Results Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, -0.12; 95% CI, -0.23 to -0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, -0.11; 95% CI, -0.22 to 0; P = .04). Conclusion and Relevance In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage. Trial Registration ClinicalTrials.gov Identifier: NCT01258257.
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Affiliation(s)
- Stefan Wolf
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Christoph Barner
- Department of Anesthesiology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich, Munich, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Farid Salih
- Department of Neurology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Doortje C. Engel
- Department of Neurosurgery, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Angelika Ehlert
- Department of Neurosurgery, Asklepios Hospital St Georg, Hamburg, Germany
| | - Dimitre Staykov
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Hospital of the Brothers of St John, Eisenstadt, Austria
| | - Abdulrahman Y. Alturki
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
- Neurovascular Surgery Section, Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Jürgen Bardutzky
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | | | - Ludwig Schürer
- Department of Neurosurgery, Klinikum Bogenhausen, Technical University Munich, Munich, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Inselspital, University of Bern, Switzerland
| | - Tareq A. Juratli
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Michael Fritsch
- Department of Neurosurgery, Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Anne Pohrt
- Department of Medical Biometrics, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich, Munich, Germany
| | - Stefan Schwab
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Kumpf O, Assenheimer M, Bloos F, Brauchle M, Braun JP, Brinkmann A, Czorlich P, Dame C, Dubb R, Gahn G, Greim CA, Gruber B, Habermehl H, Herting E, Kaltwasser A, Krotsetis S, Kruger B, Markewitz A, Marx G, Muhl E, Nydahl P, Pelz S, Sasse M, Schaller SJ, Schäfer A, Schürholz T, Ufelmann M, Waydhas C, Weimann J, Wildenauer R, Wöbker G, Wrigge H, Riessen R. Quality indicators in intensive care medicine for Germany - fourth edition 2022. Ger Med Sci 2023; 21:Doc10. [PMID: 37426886 PMCID: PMC10326525 DOI: 10.3205/000324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 07/11/2023]
Abstract
The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.
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Affiliation(s)
- Oliver Kumpf
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | | | - Frank Bloos
- Jena University Hospital, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany
| | - Maria Brauchle
- Landeskrankenhaus Feldkirch, Department of Anesthesiology and Intensive Care Medicine, Feldkirch, Austria
| | - Jan-Peter Braun
- Martin-Luther-Krankenhaus, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Alexander Brinkmann
- Klinikum Heidenheim, Department of Anesthesia, Surgical Intensive Care Medicine and Special Pain Therapy, Heidenheim, Germany
| | - Patrick Czorlich
- University Medical Center Hamburg-Eppendorf, Department of Neurosurgery, Hamburg, Germany
| | - Christof Dame
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neonatology, Berlin, Germany
| | - Rolf Dubb
- Kreiskliniken Reutlingen, Academy of the District Hospitals Reutlingen, Germany
| | - Georg Gahn
- Städt. Klinikum Karlsruhe gGmbH, Department of Neurology, Karlsruhe, Germany
| | - Clemens-A. Greim
- Klinikum Fulda, Department of Anesthesia and Surgical Intensive Care Medicine, Fulda, Germany
| | - Bernd Gruber
- Niels Stensen Clinics, Marienhospital Osnabrueck, Department Hospital Hygiene, Osnabrueck, Germany
| | - Hilmar Habermehl
- Kreiskliniken Reutlingen, Klinikum am Steinenberg, Center for Intensive Care Medicine, Reutlingen, Germany
| | - Egbert Herting
- Universitätsklinikum Schleswig-Holstein, Department of Pediatrics and Adolescent Medicine, Campus Lübeck, Germany
| | - Arnold Kaltwasser
- Kreiskliniken Reutlingen, Academy of the District Hospitals Reutlingen, Germany
| | - Sabine Krotsetis
- Universitätsklinikum Schleswig-Holstein, Nursing Development and Nursing Science, affiliated with the Nursing Directorate Campus Lübeck, Germany
| | - Bastian Kruger
- Klinikum Heidenheim, Department of Anesthesia, Surgical Intensive Care Medicine and Special Pain Therapy, Heidenheim, Germany
| | | | - Gernot Marx
- University Hospital RWTH Aachen, Department of Intensive Care Medicine and Intermediate Care, Aachen, Germany
| | | | - Peter Nydahl
- Universitätsklinikum Schleswig-Holstein, Nursing Development and Nursing Science, affiliated with the Nursing Directorate Campus Kiel, Germany
| | - Sabrina Pelz
- Universitäts- und Rehabilitationskliniken Ulm, Intensive Care Unit, Ulm, Germany
| | - Michael Sasse
- Medizinische Hochschule Hannover, Department of Pediatric Cardiology and Pediatric Intensive Care Medicine, Hanover, Germany
| | - Stefan J. Schaller
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Anesthesiology and Intensive Care Medicine, Munich, Germany
| | | | - Tobias Schürholz
- University Hospital RWTH Aachen, Department of Intensive Care Medicine and Intermediate Care, Aachen, Germany
| | - Marina Ufelmann
- Technical University of Munich, Klinikum rechts der Isar, Department of Nursing, Munich, Germany
| | - Christian Waydhas
- Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Surgical University Hospital and Polyclinic, Bochum, Germany
- Medical Department of the University of Duisburg-Essen, Essen, Germany
| | - Jörg Weimann
- Sankt-Gertrauden Krankenhaus, Department of Anesthesia and Interdisciplinary Intensive Care Medicine, Berlin, Germany
| | | | - Gabriele Wöbker
- Helios Universitätsklinikum Wuppertal, Universität Witten-Herdecke, Department of Intensive Care Medicine, Wuppertal, Germany
| | - Hermann Wrigge
- Bergmannstrost Hospital Halle, Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Halle, Germany
- Martin-Luther University Halle-Wittenberg, Medical Faculty, Halle, Germany
| | - Reimer Riessen
- Universitätsklinikum Tübingen, Department of Internal Medicine, Medical Intensive Care Unit, Tübingen, Germany
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7
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Woo MS, Mayer C, Fischer M, Kluge S, Roedl K, Gerloff C, Czorlich P, Thomalla G, Schulze Zur Wiesch J, Schweingruber N. Clinical surrogates of dysautonomia predict lethal outcome in COVID-19 on intensive care unit. Neurol Res Pract 2023; 5:17. [PMID: 37143130 PMCID: PMC10157117 DOI: 10.1186/s42466-023-00243-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/28/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Unpredictable vegetative deteriorations made the treatment of patients with acute COVID-19 on intensive care unit particularly challenging during the first waves of the pandemic. Clinical correlates of dysautonomia and their impact on the disease course in critically ill COVID-19 patients are unknown. METHODS We retrospectively analyzed data collected during a single-center observational study (March 2020-November 2021) which was performed at the University Medical Center Hamburg-Eppendorf, a large tertiary medical center in Germany. All patients admitted to ICU due to acute COVID-19 disease during the study period were included (n = 361). Heart rate variability (HRV) and blood pressure variability (BPV) per day were used as clinical surrogates of dysautonomia and compared between survivors and non-survivors at different time points after admission. Intraindividual correlation of vital signs with laboratory parameters were calculated and corrected for age, sex and disease severity. RESULTS Patients who deceased in ICU had a longer stay (median days ± IQR, survivors 11.0 ± 27.3, non-survivors 14.1 ± 18.7, P = 0.85), in contrast time spent under invasive ventilation was not significantly different (median hours ± IQR, survivors 322 ± 782, non-survivors 286 ± 434, P = 0.29). Reduced HRV and BPV predicted lethal outcome in patients staying on ICU longer than 10 days after adjustment for age, sex, and disease severity. Accordingly, HRV was significantly less correlated with inflammatory markers (e.g. CRP and Procalcitonin) and blood carbon dioxide in non-survivors in comparison to survivors indicating uncoupling between autonomic function and inflammation in non-survivors. CONCLUSIONS Our study suggests autonomic dysfunction as a contributor to mortality in critically ill COVID-19 patients during the first waves of the pandemic. Serving as a surrogate for disease progression, these findings could contribute to the clinical management of COVID-19 patients admitted to the ICU. Furthermore, the suggested measure of dysautonomia and correlation with other laboratory parameters is non-invasive, simple, and cost-effective and should be evaluated as an additional outcome parameter in septic patients treated in the ICU in the future.
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Affiliation(s)
- Marcel Seungsu Woo
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), Center for Molecular Neurobiology Hamburg (ZMNH), University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Christina Mayer
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), Center for Molecular Neurobiology Hamburg (ZMNH), University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Julian Schulze Zur Wiesch
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, 20246, Hamburg, Germany
| | - Nils Schweingruber
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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König C, Martens-Lobenhoffer J, Czorlich P, Westphal M, Bode-Böger SM, Kluge S, Grensemann J. Cerebrospinal fluid penetration of fosfomycin in patients with ventriculitis: an observational study. Ann Clin Microbiol Antimicrob 2023; 22:29. [PMID: 37095559 PMCID: PMC10127017 DOI: 10.1186/s12941-023-00572-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 03/12/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND For treatment of ventriculitis, vancomycin and meropenem are frequently used as empiric treatment but cerebrospinal fluid (CSF) penetration is highly variable and may result in subtherapeutic concentrations. Fosfomycin has been suggested for combination antibiotic therapy, but data are sparse, so far. Therefore, we studied CSF penetration of fosfomycin in ventriculitis. METHODS Adult patients receiving a continuous infusion of fosfomycin (1 g/h) for the treatment of ventriculitis were included. Routine therapeutic drug monitoring (TDM) of fosfomycin in serum and CSF was performed with subsequent dose adaptions. Demographic and routine laboratory data including serum and CSF concentrations for fosfomycin were collected. Antibiotic CSF penetration ratio as well as basic pharmacokinetic parameters were investigated. RESULTS Seventeen patients with 43 CSF/serum pairs were included. Median fosfomycin serum concentration was 200 [159-289] mg/L and the CSF concentration 99 [66-144] mg/L. Considering only the first measurements in each patient before a possible dose adaption, serum and CSF concentrations were 209 [163-438] mg/L and 104 [65-269] mg/L. Median CSF penetration was 46 [36-59]% resulting in 98% of CSF levels above the susceptibility breakpoint of 32 mg/L. CONCLUSION Penetration of fosfomycin into the CSF is high, reliably leading to appropriate concentrations for the treatment of gram positive and negative bacteria. Moreover, continuous administration of fosfomycin appears to be a reasonable approach for antibiotic combination therapy in patients suffering from ventriculitis. Further studies are needed to evaluate the impact on outcome parameters.
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Affiliation(s)
- Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jens Martens-Lobenhoffer
- Institute of Clinical Pharmacology, Otto-Von-Guericke University, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefanie M Bode-Böger
- Institute of Clinical Pharmacology, Otto-Von-Guericke University, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Czorlich P, Schweingruber N, Göttsche J, Mader MM, Westphal M. Acute low-pressure hydrocephalus in aneurysmal subarachnoid hemorrhage. Neurosurg Focus 2023; 54:E5. [PMID: 37004138 DOI: 10.3171/2023.1.focus22639] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/17/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE Acute and chronic hydrocephalus are common pathologies after aneurysmal subarachnoid hemorrhage (SAH). Generally, the presence of acute hydrocephalus is associated with elevated intracranial pressure (ICP) treated with a ventricular drain. Subsequently, however, pronounced hydrocephalus without elevated ICP may develop in some patients with SAH in the postacute phase. This is described as acute low-pressure hydrocephalus (aLPH), and there are very limited data in the literature of this pathology. The aim of this study was to evaluate the rate of and factors associated with aLPH and describe its clinical course. METHODS In this retrospective single-center cohort study, the frequency and clinical characteristics of SAH-associated aLPH were investigated. Acute LPH was defined as an increase in ventricular size as measured by the Evans index, ICP within the normal range (< 5 mm Hg) at the time of ventricular enlargement, and timely neurological improvement after indwelling ventricular CSF drainage with negative pressure up to 5 cm H2O below normal level. Demographic and SAH-specific factors in patients with SAH treated using an external ventricular drain were extracted from the electronic medical chart and further analyzed. RESULTS From November 2010 to May 2020, 15 (3.7.%) of 406 patients with SAH fulfilled the criteria for aLPH. Acute LPH was diagnosed after an average of 13.1 ± 7.7 days. The presence of IVH and its extension were associated with the occurrence of aLPH. After undergoing the transient phase of aLPH, these patients subsequently developed a chronic, typical malresorptive hydrocephalus requiring a ventriculoperitoneal shunt more often (66.7% vs 17.4%, p < 0.001) and stayed longer in the intensive care unit (27 vs 20.5 days, p = 0.043) and in the hospital (36.4 vs 26.3 days, p = 0.004). CONCLUSIONS Acute LPH is a rare pathology in patients with SAH and negatively impacts the clinical course. It should be especially considered in patients with a lack of neurological improvement, an increase in ventricular width, and normal ICP values, so that forced CSF drainage is implemented.
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Affiliation(s)
| | - Nils Schweingruber
- 2Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and
| | | | - Marius M Mader
- Departments of1Neurosurgery and
- 3Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California
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10
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Güresir E, Lampmann T, Bele S, Czabanka M, Czorlich P, Gempt J, Goldbrunner R, Hurth H, Hermann E, Jabbarli R, Krauthausen M, König R, Lindner D, Malinova V, Meixensberger J, Mielke D, Németh R, Darkwah Oppong M, Pala A, Prinz V, Rashidi A, Roder C, Sandalcioglu IE, Sauvigny T, Schebesch KM, Timmer M, Vajkoczy P, Wessels L, Wild F, Wilhelm C, Wostrack M, Vatter H, Coch C. Fight INflammation to Improve outcome after aneurysmal Subarachnoid HEmorRhage (FINISHER) trial: Study protocol for a randomized controlled trial. Int J Stroke 2023; 18:242-247. [PMID: 35361026 DOI: 10.1177/17474930221093501] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RATIONALE Aneurysmal subarachnoid hemorrhage (SAH) has high morbidity and mortality. While the primary injury results from the initial bleeding cannot currently be influenced, secondary injury through vasospasm and delayed cerebral ischemia worsens outcome and might be a target for interventions to improve outcome. To date, beside the aneurysm treatment to prevent re-bleeding and the administration of oral nimodipine, there is no therapy available, so novel treatment concepts are needed. Evidence suggests that inflammation contributes to delayed cerebral ischemia and poor outcome in SAH. Some studies suggest a beneficial effect of anti-inflammatory glucocorticoids, but there are no data from randomized controlled trials examining the efficacy of glucocorticoids. Therefore, current guidelines do not recommend the use of glucocorticoids in SAH. AIM The Fight INflammation to Improve outcome after aneurysmal Subarachnoid HEmorRhage (FINISHER) trial aims to determine whether dexamethasone improves outcome in a clinically relevant endpoint in SAH patients. METHODS AND DESIGN FINISHER is a multicenter, prospective, randomized, double-blinded, placebo-controlled clinical phase III trial which is testing the outcome and safety of anti-inflammatory treatment with dexamethasone in SAH patients. SAMPLE SIZE ESTIMATES In all, 334 patients will be randomized to either dexamethasone or placebo within 48 h after SAH. The dexamethasone dose is 8 mg tds for days 1-7 and then 8 mg od for days 8-21. STUDY OUTCOME The primary outcome is the modified Rankin Scale (mRS) at 6 months, which is dichotomized to favorable (mRS 0-3) versus unfavorable (mRS 4-6). DISCUSSION The results of this study will provide the first phase III evidence as to whether dexamethasone improves outcome in SAH.
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Affiliation(s)
- Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Tim Lampmann
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Sylvia Bele
- Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Johann Wolfgang Goethe-Universität Frankfurt am Main, Frankfurt, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Roland Goldbrunner
- Department of General Neurosurgery, Center for Neurosurgery, University of Cologne, Cologne, Germany
| | - Helene Hurth
- Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Elvis Hermann
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Marius Krauthausen
- Clinical Study Core Unit, Study Center Bonn (SZB), University Hospital Bonn, Bonn, Germany
| | - Ralph König
- Department of Neurosurgery, University of Ulm/BKH Günzburg, Günzburg, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Vesna Malinova
- Department of Neurosurgery, Georg-August-Universität Göttingen, Göttingen, Germany
| | | | - Dorothee Mielke
- Department of Neurosurgery, Georg-August-Universität Göttingen, Göttingen, Germany
| | - Robert Németh
- Institute of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm/BKH Günzburg, Günzburg, Germany
| | - Vincent Prinz
- Department of Neurosurgery, Johann Wolfgang Goethe-Universität Frankfurt am Main, Frankfurt, Germany
| | - Ali Rashidi
- Department of Neurosurgery, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Constantin Roder
- Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | | | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Marco Timmer
- Department of General Neurosurgery, Center for Neurosurgery, University of Cologne, Cologne, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Wessels
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Wild
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Christoph Wilhelm
- Immunopathology Unit, Institute of Clinical Chemistry and Clinical Pharmacology, Medical Faculty, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Christoph Coch
- Clinical Study Core Unit, Study Center Bonn (SZB), University Hospital Bonn, Bonn, Germany
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Piffko A, Ricklefs FL, Schweingruber N, Sauvigny T, Mader MMD, Mohme M, Dührsen L, Westphal M, Regelsberger J, Schmidt NO, Czorlich P. Corticosteroid-Dependent Leukocytosis Masks the Predictive Potential of White Blood Cells for Delayed Cerebral Ischemia and Ventriculoperitoneal Shunt Dependency in Aneurysmatic Subarachnoid Hemorrhage. J Clin Med 2023; 12:jcm12031006. [PMID: 36769654 PMCID: PMC9917511 DOI: 10.3390/jcm12031006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/21/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
A multitude of pathological and inflammatory processes determine the clinical course after aneurysmal subarachnoid hemorrhage (aSAH). However, our understanding of predictive factors and therapeutic consequences is limited. We evaluated the predictive value of clinically relevant factors readily available in the ICU setting, such as white blood cell (WBC) count and CRP, for two of the leading comorbidities, delayed cerebral ischemia (DCI) and ventriculoperitoneal (VP) shunt dependency in aSAH patients with and without corticosteroid treatment. We conducted a retrospective analysis of 484 aSAH patients admitted to our institution over an eight-year period. Relevant clinical factors affecting the risk of DCI and VP shunt dependency were identified and included in a multivariate logistic regression model. Overall, 233/484 (48.1%) patients were treated with corticosteroids. Intriguingly, predictive factors associated with the occurrence of DCI differed significantly depending on the corticosteroid treatment status (dexamethasone group: Hunt and Hess grade (p = 0.002), endovascular treatment (p = 0.016); no-dexamethasone group: acute hydrocephalus (p = 0.018), peripheral leukocyte count 7 days post SAH (WBC at day 7) (p = 0.009)). Similar disparities were found for VP shunt dependency (dexamethasone group: acute hydrocephalus (p = 0.002); no-dexamethasone group: WBC d7 (p = 0.036), CRP peak within 72 h (p = 0.015)). Our study shows that corticosteroid-induced leukocytosis negates the predictive prognostic potential of systemic inflammatory markers for DCI and VP shunt dependency, which has previously been neglected and should be accounted for in future studies.
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Affiliation(s)
- Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL 60637, USA
- Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL 60637, USA
| | - Franz L. Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Nils Schweingruber
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Malte Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, Diako Hospital Flensburg, 24939 Flensburg, Germany
| | - Nils Ole Schmidt
- Department of Neurosurgery, Regensburg University Hospital, 93053 Regensburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
- Correspondence: ; Tel.: +49-40-7410-50753
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Mader MMD, Lefering R, Westphal M, Maegele M, Czorlich P. Extracorporeal membrane oxygenation in traumatic brain injury - A retrospective, multicenter cohort study. Injury 2023; 54:1271-1277. [PMID: 36621363 DOI: 10.1016/j.injury.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 12/14/2022] [Accepted: 01/01/2023] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Patients with traumatic brain injury (TBI) regularly require intensive care with prolonged invasive ventilation. Consequently, these patients are at increased risk of pulmonary failure, potentially requiring extracorporeal membrane oxygenation (ECMO). The aim of this work was to provide an overview of ECMO treatment in TBI patients based upon data captured into the TraumaRegister DGU® (TR-DGU). METHODS A retrospective multi-center cohort analysis of patients registered in the TR-DGU was conducted. Adult patients with relevant TBI (AISHead ≥3) who had been treated in German, Austrian, or Swiss level I or II trauma centers using ECMO therapy between 2015 and 2019 were included. A multivariable logistic regression analysis was used to identify risk factors for the need for ECMO treatment. RESULTS 12,247 patients fulfilled the inclusion criteria. The overall rate of ECMO treatment was 1.1% (134 patients). Patients on ECMO had an overall hospital mortality rate of 38% (51/134 patients) while 13% (1523/12,113 patients) of TBI patients without ECMO therapy died. Male gender (p = 0.014), AISChest 3+ (p<0.001), higher Injury Severity Score (p<0.001) and packed red blood cell (pRBC) transfusion (p<0.001) were associated with ECMO treatment. CONCLUSION ECMO therapy is a potentially lifesaving modality for the treatment of moderate-to-severe TBI when combined with severe chest trauma and pulmonary failure. The in-hospital mortality is increased in this high-risk population, but the majority of patients is surviving.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Federal Republic of Germany; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Federal Republic of Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Federal Republic of Germany
| | - Marc Maegele
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Federal Republic of Germany; Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Federal Republic of Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Federal Republic of Germany.
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Grensemann J, Mader MMD, Westphal M, Kluge S, Czorlich P. Hyperoxia is Dose-Dependently Associated with an Increase of Unfavorable Outcomes in Ventilated Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study. Neurocrit Care 2022; 37:523-530. [PMID: 35672497 PMCID: PMC9519732 DOI: 10.1007/s12028-022-01534-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/05/2022] [Indexed: 11/05/2022]
Abstract
Background Adequate oxygenation in patients with aneurysmal subarachnoid hemorrhage (SAH) is imperative. However, hyperoxia increases formation of reactive oxygen species and may be associated with a dose-dependent toxicity. We postulated a threshold for arterial partial pressure of oxygen (paO2) above which toxicity effects precipitate and sought to study the effects on 30-day mortality, favorable outcome at discharge and at 3 months, and delayed cerebral ischemia. Methods In this retrospective single-center cohort study, patients with SAH and mechanical ventilation > 72 h were included. Oxygen integrals were calculated above the following thresholds: 80, 100, 120, and 150 mm Hg and time-weighted mean paO2. All calculations were done from admission to end of day 1, day 3, and day 14. We conducted multivariable logistic regression analyses adjusted for age, sex, duration of ventilation, and Hunt and Hess grade. Time-weighted mean paO2 was categorized by quartiles. Favorable outcome was defined as Glasgow Outcome Scale scores of 4 and 5. Results From November 2010 to February 2021, 282 of 549 patients fulfilled the inclusion criteria. Odds ratios for 30-day mortality increased dose dependently and were as follows: 1.07 (95% confidence interval [CI] 1.03–1.11; p = 0.001) for each 1 mm Hg per day above 80 mm Hg; 1.16 (95% CI 1.07–1.27), above 100 mm Hg; 1.36 (95% CI 1.15–1.61), above 120 mm Hg; and 1.59 (95% CI 1.22–2.08), above 150 mm Hg (all p < 0.001) at day 14. For favorable outcome at 3 months, odds ratios were 0.96 (95% CI 0.92–0.99) for each 1 mm Hg per day above 80 mm Hg; 0.90 (95% CI 0.84–0.98), above 100 mm Hg; 0.83 (95% CI 0.72–0.97), above 120 mm Hg; and 0.77 (95% CI 0.61–0.97), above 150 mm Hg (all p < 0.05). For time-weighted mean paO2, lowest 30-day mortality and highest favorable outcome at 3 months were found in the second quartile (78–85 mm Hg). Thirty-day mortality increased above 93 mm Hg (fourth quartile), with an odds ratio of 3.4 (95% CI 1.4–8.4, p = 0.007). Odds ratios for favorable outcome at 3 months were 0.28 (95% CI 0.12–0.69), 0.27 (95% CI 0.11–0.67), and 0.24 (95% CI 0.10–0.59) for the first, third, and fourth quartiles, respectively (all p < 0.01). No significant association was found at day 1 and day 3, for favorable outcome at discharge, or for delayed cerebral ischemia. Conclusions Integrals above the defined paO2 thresholds were dose-dependently associated with an increase in mortality in ventilated patients with SAH. When we considered time-weighted mean paO2, unfavorable outcomes and 30-day mortality were more frequent both below and above a certain range. Unfavorable outcomes increased in paO2 ranges usually defined as normoxia. This emphasizes the necessity to further characterize oxygenation thresholds in ventilated patients with SAH in prospective clinical studies. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01534-y.
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Göttsche J, Piffko A, Pantel TF, Westphal M, Dührsen L, Czorlich P, Sauvigny T. Aneurysm Location Affects Clinical Course and Mortality in Patients With Subarachnoid Hemorrhage. Front Neurol 2022; 13:846066. [PMID: 35359650 PMCID: PMC8964037 DOI: 10.3389/fneur.2022.846066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/28/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The influence of preexisting factors on the clinical course of patients with subarachnoid hemorrhage (SAH), such as patient age, arterial hypertension, and aneurysm characteristics, is still a matter of debate. However, the specific impact of the exact aneurysm location has not received adequate attention. Therefore, the aim of this study was to investigate the influence of aneurysm location as a preexisting factor on the clinical course and mortality. Methods The data of consecutive patients with aneurysmal SAH who were treated from October 2010 to July 2020 were retrospectively analyzed. We distinguished four aneurysm locations: the anterior complex, internal carotid artery (ICA), middle cerebral artery (MCA), and posterior circulation. Logistic regression analysis and receiver operating characteristics were used to investigate the influence of aneurysm location on the occurrence of acute hydrocephalus, Delayed Cerebral Ischemia (DCI), neurological outcome, and in-hospital mortality. Neurological outcome was assessed 3 months after discharge using the Glasgow Outcome Scale. Results A total of 603 patients were included in this study. Patients with MCA aneurysms were 2.52 times less likely to develop acute hydrocephalus compared to patients with anterior complex aneurysms (p = 0.001). Delayed cerebral ischemia occurred most frequently in patients with an anterior complex aneurysm and least frequently in MCA aneurysms (p = 0.014). In ICA aneurysms, mortality was 2.56-fold higher than in patients with aneurysms of the anterior complex (p = 0.006). An additional ROC analysis showed a good prediction for in-hospital mortality when taking the aneurysm's location into account [AUC.855 (CI.817 −0.893)]. Conclusions The aneurysm's location proved to be a significant predictor of acute hydrocephalus, DCI, and in-hospital mortality, demonstrating the impact of this preexisting biological factor on the course of SAH.
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Affiliation(s)
- Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias F Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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15
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König C, Grensemann J, Czorlich P, Schlemm E, Kluge S, Wicha SG. A dosing nomograph for cerebrospinal fluid penetration of meropenem applied by continuous infusion in patients with nosocomial ventriculitis. Clin Microbiol Infect 2022; 28:1022.e9-1022.e16. [PMID: 35182756 DOI: 10.1016/j.cmi.2022.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In difficult to treat infections such as nosocomial ventriculitis, meropenem exposure in the infected compartment is often uncertain but crucial for antibacterial effects. The aim of this study was to investigate the cerebrospinal fluid (CSF) penetration of meropenem in patients with nosocomial ventriculitis and to derive a nomograph to predict effective meropenem doses as a function of clinical parameters. METHODS Retrospective patient data including meropenem serum and CSF levels, as well as CSF inflammation markers were analysed using NONMEM® to assess the general pharmacokinetics and CSF penetration. Monte Carlo simulations (MCS) were used to evaluate different meropenem dosing regimens. Probability of target attainment (PTA) in CSF was assessed and a nomograph to achieve a target concentration of 4 mg/L was developed. RESULTS A one-compartment model with meropenem clearance dependent on the estimated glomerular filtration rate (CKD-EPI eGFR, p< 5 e-10) best described meropenem serum pharmacokinetics of 51 critically ill patients. CSF penetration ratio was correlated with the amount of protein in CSF (p< 1 e-8), with higher CSF protein levels accounting for higher penetration ratios. Preserved renal function (CKD-EPI GFR> 50 ml/min/1.73 m2) as well as low CSF protein levels (<500 mg/L) resulted in 80 % PTA (100 %fT>2xMIC) for a meropenem dose of 6 g/24 h. CONCLUSIONS High interindividual variability in meropenem CSF concentration was observed in patients with nosocomial ventriculitis. A nomograph to predict the daily meropenem dose required for target attainment for a given eGFR and CSF protein count was developed.
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Affiliation(s)
- Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Germany; Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Germany.
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University Hamburg, Germany
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16
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Schweingruber N, Mader M, Wiehe A, Röder F, Göttsche J, Kluge S, Westphal M, Czorlich P, Gerloff C. A recurrent machine learning model predicts intracranial hypertension in neurointensive care patients. Brain 2022; 145:2910-2919. [PMID: 35139181 PMCID: PMC9486888 DOI: 10.1093/brain/awab453] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/24/2021] [Accepted: 11/19/2021] [Indexed: 11/14/2022] Open
Abstract
The evolution of intracranial pressure (ICP) of critically ill patients admitted to a neurointensive care unit (ICU) is difficult to predict. Besides the underlying disease and compromised intracranial space, ICP is affected by a multitude of factors, many of which are monitored on the ICU, but the complexity of the resulting patterns limits their clinical use. This paves the way for new machine learning (ML) techniques to assist clinical management of patients undergoing invasive ICP monitoring independent of the underlying disease. An institutional cohort (ICP-ICU) of patients with invasive ICP monitoring (n = 1346) was used to train recurrent ML models to predict the occurrence of ICP increases of ≥ 22mmHg over a long (> 2 hours) time period in the upcoming hours. External validation was performed on patients undergoing invasive ICP measurement in two publicly available datasets (Medical Information Mart for Intensive Care (MIMIC, n = 998) and eICU Collaborative Research Database (eICU, n = 1634)). Different distances (1h-24 h) between prediction time point and upcoming critical phase were evaluated, demonstrating a decrease in performance but still robust AUC-ROC with larger distances (24 h AUC-ROC: ICP-ICU 0.826 ± 0.0071, MIMIC 0.836 ± 0.0063, eICU 0.779 ± 0.0046, 1 h AUC-ROC: ICP-ICU 0.982 ± 0.0008, MIMIC 0.965 ± 0.0010, eICU 0.941 ± 0.0025). The model operates on sparse hourly data and is stable in handling variable input lengths and missingness through its nature of recurrence and internal memory. Calculation of gradient-based feature importance revealed individual underlying decisions for our Long Short Time Memory (LSTM) based model and thereby provided improved clinical interpretability. Recurrent ML models have the potential to be an effective tool for the prediction of ICP increases with high translational potential.
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Affiliation(s)
- Nils Schweingruber
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany
| | - Marius Mader
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg 20246, Germany.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University
| | - Anton Wiehe
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany.,Department of Informatics, University of Hamburg, Hamburg, 22527, Germany
| | - Frank Röder
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany.,Department of Informatics, University of Hamburg, Hamburg, 22527, Germany
| | - Jennifer Göttsche
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany
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17
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Pantel T, Roedl K, Jarczak D, Yu Y, Frings DP, Sensen B, Pinnschmidt H, Bernhardt A, Cheng B, Lettow I, Westphal M, Czorlich P, Kluge S, Fischer M. Association of COVID-19 with Intracranial Hemorrhage during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: A 10-Year Retrospective Observational Study. J Clin Med 2021; 11:jcm11010028. [PMID: 35011769 PMCID: PMC8745037 DOI: 10.3390/jcm11010028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 02/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is potentially lifesaving for patients with acute respiratory distress syndrome (ARDS) but may be accompanied by serious adverse events, including intracranial hemorrhage (ICRH). We hypothesized that ICRH occurs more frequently in patients with COVID-19 than in patients with ARDS of other etiologies. We performed a single-center retrospective analysis of adult patients treated with venovenous (vv-) ECMO for ARDS between January 2011 and April 2021. Patients were included if they had received a cranial computed tomography (cCT) scan during vv-ECMO support or within 72 h after ECMO removal. Cox regression analysis was used to identify factors associated with ICRH. During the study period, we identified 204 patients with vv-ECMO for ARDS, for whom a cCT scan was available. We observed ICRH in 35.4% (n = 17/48) of patients with COVID-19 and in 16.7% (n = 26/156) of patients with ARDS attributable to factors other than COVID-19. COVID-19 (HR: 2.945; 95%; CI: 1.079–8.038; p = 0.035) and carboxyhemoglobin (HR: 0.330; 95%; CI: 0.135–0.806; p = 0.015) were associated with ICRH during vv-ECMO. In patients receiving vv-ECMO, the incidence of ICRH is doubled in patients with COVID-19 compared to patients suffering from ARDS attributable to other causes. More studies on the association between COVID-19 and ICRH during vv-ECMO are urgently needed to identify risk patterns and targets for potential therapeutic interventions.
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Affiliation(s)
- Tobias Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (T.P.); (M.W.); (P.C.)
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (K.R.); (D.J.); (D.P.F.); (B.S.); (S.K.)
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (K.R.); (D.J.); (D.P.F.); (B.S.); (S.K.)
| | - Yuanyuan Yu
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Daniel Peter Frings
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (K.R.); (D.J.); (D.P.F.); (B.S.); (S.K.)
| | - Barbara Sensen
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (K.R.); (D.J.); (D.P.F.); (B.S.); (S.K.)
| | - Hans Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Alexander Bernhardt
- Department for Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (B.C.); (I.L.)
| | - Iris Lettow
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (B.C.); (I.L.)
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (T.P.); (M.W.); (P.C.)
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (T.P.); (M.W.); (P.C.)
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (K.R.); (D.J.); (D.P.F.); (B.S.); (S.K.)
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (K.R.); (D.J.); (D.P.F.); (B.S.); (S.K.)
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
- Correspondence: ; Tel.: +49-15222827500
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18
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Abstract
Nitric oxide is an important mediator of vascular autoregulation and is involved in pathophysiological changes after acute neurological disorders. Nitric oxide is generated by nitric oxide synthases from the amino acid L-arginine. L-arginine can also serve as a substrate for arginases or lead to the generation of dimethylarginines, asymmetric dimethylarginine, and symmetric dimethylarginine, by methylation. Asymmetric dimethylarginine is an endogenous inhibitor of nitric oxide synthase and can lead to endothelial dysfunction. This review discusses the role of L-arginine metabolism in patients suffering from acute and critical neurological disorders often requiring neuro-intensive care treatment. Conditions addressed in this review include intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, and traumatic brain injury. Recent therapeutic advances in the field are described including current randomized controlled trials for traumatic brain injuries and hemorrhagic stroke.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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19
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Göttsche J, Schweingruber N, Groth JC, Gerloff C, Westphal M, Czorlich P. Safety and Clinical Effects of Switching From Intravenous to Oral Nimodipine Administration in Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2021; 12:748413. [PMID: 34867733 PMCID: PMC8636241 DOI: 10.3389/fneur.2021.748413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Several guidelines recommend oral administration of nimodipine as vasospasm prophylaxis after aneurysmal subarachnoid hemorrhage (SAH). However, in clinical practice, the drug is administered orally and intravenously (i.v.), depending on clinical conditions and local treatment regimens. We have therefore investigated the safety and clinical effects of switching from i.v. to oral nimodipine therapy. Methods: Patients with aneurysmal SAH between January 2014 and April 2018 and initial i.v. nimodipine therapy, which was subsequently switched to oral administration, were included in this retrospective study. Transcranial Doppler sonography (TCD) of the vessels of the anterior circulation was performed daily. The occurrence of vasospasm and infarction during the overall course of the treatment was recorded. Statistical level of significance was set to p < 0.05. Results: A total of 133 patients (mean age 55.8 years, 65% female) initially received nimodipine i.v. after aneurysmal SAH, which was subsequently switched to oral administration after a mean of 12 days. There were no significant increases in mean flow velocities on TCD after the switch from i.v. to oral nimodipine administration regarding the anterior cerebral artery. For the middle cerebral artery, an increase from 62.36 to 71.78 cm/sec could only be detected in the subgroup of patients with infarction. There was no clustering of complicating events such as new-onset vasospasm or infarction during or after the switch. Conclusions: Our results do not point to any safety concerns when switching nimodipine from initial i.v. to oral administration. Switching was neither associated with clinically relevant increases in TCD velocities nor other relevant adverse events.
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Affiliation(s)
- Jennifer Göttsche
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Nils Schweingruber
- Department of Neurology, Hamburg University Medical Center, Hamburg, Germany
| | | | - Christian Gerloff
- Department of Neurology, Hamburg University Medical Center, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
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20
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Mader MM, Böger R, Appel D, Schwedhelm E, Haddad M, Mohme M, Lamszus K, Westphal M, Czorlich P, Hannemann J. Intrathecal and systemic alterations of L-arginine metabolism in patients after intracerebral hemorrhage. J Cereb Blood Flow Metab 2021; 41:1964-1977. [PMID: 33461409 PMCID: PMC8327100 DOI: 10.1177/0271678x20983216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Alterations in the concentration of nitric oxide (NO) and L-arginine metabolites have been associated with the pathophysiology of different vascular diseases. Here, we describe striking changes in L-arginine metabolism after hemorrhagic stroke. Blood and cerebrospinal fluid (CSF) samples of patients with intracerebral hemorrhage (ICH) and/or intraventricular hemorrhage were collected over a ten-day period. Liquid chromatography-tandem mass spectrometry was used to quantify key substrates and products of L-arginine metabolizing enzymes as well as asymmetric (ADMA) and symmetric dimethylarginine (SDMA). Changes in the plasma were limited to early reductions in L-ornithine, L-lysine, and L-citrulline concentrations. Intrathecally, we observed signs of early NO synthase (NOS) upregulation followed by a decrease back to baseline accompanied by a rise in the level of its endogenous NOS-inhibitor ADMA. SDMA demonstrated increased levels throughout the observation period. For arginase, a pattern of persistently elevated activity was measured and arginine:glycine amidinotransferase (AGAT) appeared to be reduced in its activity at later time points. An early reduction in CSF L-arginine concentration was an independent risk factor for poor outcome. Together, these findings further elucidate pathophysiological mechanisms after ICH potentially involved in secondary brain injury and may reveal novel therapeutic targets.
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Affiliation(s)
- Marius M Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Rainer Böger
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Appel
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Edzard Schwedhelm
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Munif Haddad
- Department of Clinical Chemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katrin Lamszus
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Juliane Hannemann
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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Berger-Groch J, Rueger JM, Czorlich P, Frosch KH, Lefering R, Hoffmann M. Evaluation of Pelvic Circular Compression Devices in Severely Injured Trauma Patients with Pelvic Fractures. PREHOSP EMERG CARE 2021; 26:547-555. [PMID: 34152927 DOI: 10.1080/10903127.2021.1945717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: The role of pelvic circumferential compression devices (PCCD) is to temporarily stabilize the pelvic ring, reduce its volume and to tamponade bleeding. The purpose of this study was to evaluate the effect of PCCDs on mortality and bleeding in severely injured trauma patients, using a large registry database.Methods: We performed a retrospective analysis of all patients registered in the Trauma Register DGU® between 2015 and 2016. The study was limited to directly admitted patients who were alive on admission, with an injury severity score (ISS) of 9 or higher, with an Abbreviated Injury Scale AISpelvis of 3-5, aged at least 16, and with complete status documentation on pelvic circular compression devices (PCCD) and mortality. A cohort analysis was undertaken of patients suffering from relevant pelvic fractures. Data were collected on mortality and requirements for blood transfusion. The observed outcome was compared with the expected outcome as derived from version II of the Revised Injury Severity Classification (RISC II) and adjusted accordingly. A Standardized Mortality Ratio (SMR) was also calculated.Results: A total of 9,910 patients were included. 1,103 of 9,910 patients suffered from a relevant pelvic trauma (AISpelvis = 3-5). Only 41% (454 cases) of these received a PCCD. PCCD application had no significant effect on mortality and did not decrease the need for blood transfusion in the multivariate regression analysis. However, in this cohort, the application of a PCCD is a general indicator for a critical patient with increased mortality (12.0% no PCCD applied vs. 23.2% PCCD applied prehospital vs. 27.1% PCCD applied in the emergency department). The ISS was higher in patients with PCCD (34.12 ± 16.4 vs. 27.9 ± 13.8; p < 0.001).Conclusion: PCCD was applied more often in patients with severe pelvic trauma according to ISS and AISpelvis as well with deterioration in circulatory status. PCCDs did not reduce mortality or reduce the need for blood transfusion.Trial registration: TR-DGU ID 2017-003, March 2017; German clinical trial register DRKS00024948.
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Affiliation(s)
- Josephine Berger-Groch
- Received April 3, 2021 from Department of Trauma and Orthopedic Surgery, University Medical Center, Hamburg, Germany (JB-G, JMR, K-HF, MH); Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (PC); Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany (RL); Department of Orthopaedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany (MH). Revised received June 11, 2021; accepted for publication June 15, 2021
| | - Johannes Maria Rueger
- Received April 3, 2021 from Department of Trauma and Orthopedic Surgery, University Medical Center, Hamburg, Germany (JB-G, JMR, K-HF, MH); Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (PC); Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany (RL); Department of Orthopaedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany (MH). Revised received June 11, 2021; accepted for publication June 15, 2021
| | - Patrick Czorlich
- Received April 3, 2021 from Department of Trauma and Orthopedic Surgery, University Medical Center, Hamburg, Germany (JB-G, JMR, K-HF, MH); Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (PC); Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany (RL); Department of Orthopaedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany (MH). Revised received June 11, 2021; accepted for publication June 15, 2021
| | - Karl-Heinz Frosch
- Received April 3, 2021 from Department of Trauma and Orthopedic Surgery, University Medical Center, Hamburg, Germany (JB-G, JMR, K-HF, MH); Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (PC); Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany (RL); Department of Orthopaedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany (MH). Revised received June 11, 2021; accepted for publication June 15, 2021
| | - Rolf Lefering
- Received April 3, 2021 from Department of Trauma and Orthopedic Surgery, University Medical Center, Hamburg, Germany (JB-G, JMR, K-HF, MH); Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (PC); Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany (RL); Department of Orthopaedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany (MH). Revised received June 11, 2021; accepted for publication June 15, 2021
| | - Michael Hoffmann
- Received April 3, 2021 from Department of Trauma and Orthopedic Surgery, University Medical Center, Hamburg, Germany (JB-G, JMR, K-HF, MH); Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (PC); Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany (RL); Department of Orthopaedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany (MH). Revised received June 11, 2021; accepted for publication June 15, 2021
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- Received April 3, 2021 from Department of Trauma and Orthopedic Surgery, University Medical Center, Hamburg, Germany (JB-G, JMR, K-HF, MH); Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (PC); Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany (RL); Department of Orthopaedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany (MH). Revised received June 11, 2021; accepted for publication June 15, 2021
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22
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Mader MMD, Rotermund R, Lefering R, Westphal M, Maegele M, Czorlich P. The faster the better? Time to first CT scan after admission in moderate-to-severe traumatic brain injury and its association with mortality. Neurosurg Rev 2020; 44:2697-2706. [PMID: 33340052 PMCID: PMC8490239 DOI: 10.1007/s10143-020-01456-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
Fast acquisition of a first computed tomography (CT) scan after traumatic brain injury (TBI) is recommended. This study is aimed at investigating whether the length of the period preceding initial CT scan influences mortality in patients with leading TBI. A retrospective cohort analysis of patients registered in the TraumaRegister DGU® was conducted including adult patients with TBI, defined as Abbreviated Injury ScaleHead ≥ 3 and GCS ≤ 13 who had been treated in level 1 or 2 trauma centers from 2007-2016. Patients were grouped according to time intervals either from trauma or from admission to CT. A total of 6904 patients met the inclusion criteria. Mean time period from trauma to hospital admission was 68.8 min. From admission to first CT, a mean of 19.0 min elapsed. Trauma severity was higher in groups with a longer duration from trauma to CT as represented by a mean (± standard deviation) Injury Severity Score (ISS) of 19.8 ± 9.0, 20.7 ± 9.3, and 21.4 ± 7.5 and similar distribution of mortality of 24.9%, 29.9%, and 36.3% in the ≤ 60-min, 61-120-min, and ≥ 121-min groups, respectively. An adjusted multivariable logistic regression model showed a significant influence of the level of the trauma center (p = 0.037) but not for interval from admission to CT (p = 0.528). TBI patients with a longer time span from trauma to first CT were more severely injured and demonstrated a worse prognosis, but received a CT scan faster when duration from admission is observed. The duration until the CT scan was obtained showed no significant impact on the mortality.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Rolf Lefering
- Institute of Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marc Maegele
- Institute of Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany.,Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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23
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Mader MMD, Lefering R, Westphal M, Maegele M, Czorlich P. Traumatic brain injury with concomitant injury to the spleen: characteristics and mortality of a high-risk trauma cohort from the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2020; 48:4451-4459. [PMID: 33206232 DOI: 10.1007/s00068-020-01544-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/31/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Based on the hypothesis that systemic inflammation contributes to secondary injury after initial traumatic brain injury (TBI), this study aims to describe the effect of splenectomy on mortality in trauma patients with TBI and splenic injury. METHODS A retrospective cohort analysis of patients prospectively registered into the TraumaRegister DGU® (TR-DGU) with TBI (AISHead ≥ 3) combined with injury to the spleen (AISSpleen ≥ 1) was conducted. Multivariable logistic regression modeling was performed to adjust for confounding factors and to assess the independent effect of splenectomy on in-hospital mortality. RESULTS The cohort consisted of 1114 patients out of which 328 (29.4%) had undergone early splenectomy. Patients with splenectomy demonstrated a higher Injury Severity Score (median: 34 vs. 44, p < 0.001) and lower Glasgow Coma Scale (median: 9 vs. 7, p = 0.014) upon admission. Splenectomized patients were more frequently hypotensive upon admission (19.8% vs. 38.0%, p < 0.001) and in need for blood transfusion (30.3% vs. 61.0%, p < 0.001). The mortality was 20.7% in the splenectomy group and 10.3% in the remaining cohort. After adjustment for confounding factors, early splenectomy was not found to exert a significant effect on in-hospital mortality (OR 1.29 (0.67-2.50), p = 0.45). CONCLUSION Trauma patients with TBI and spleen injury undergoing splenectomy demonstrate a more severe injury pattern, more compromised hemodynamic status and higher in-hospital mortality than patients without splenectomy. Adjustment for confounding factors reveals that the splenectomy procedure itself is not independently associated with survival.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany. .,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, 265 Campus Drive, Stanford, CA, 94305, USA.
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marc Maegele
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, 51109, Cologne, Germany.,Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Center, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Huckhagel T, Klinger R, Schmidt NO, Regelsberger J, Westphal M, Czorlich P. The burden of headache following aneurysmal subarachnoid hemorrhage: a prospective single-center cross-sectional analysis. Acta Neurochir (Wien) 2020; 162:893-903. [PMID: 32016589 PMCID: PMC7066282 DOI: 10.1007/s00701-020-04235-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/18/2020] [Indexed: 12/17/2022]
Abstract
Background Aneurysmal subarachnoid hemorrhage (SAH) as a serious type of stroke is frequently accompanied by a so-called initial thunderclap headache. However, the occurrence of burdensome long-term headache following SAH has never been studied in detail so far. The aim of this study was to determine the prevalence and characteristics of long-term burdensome headache in good-grade SAH patients as well as its relation to health-related quality of life (HR-QOL). Methods All SAH cases treated between January 2014 and December 2016 with preserved consciousness at hospital discharge were prospectively interviewed regarding burdensome headache in 2018. Study participants were subsequently scrutinized by means of a standardized postal survey comprising validated pain and HR-QOL questionnaires. A retrospective chart review provided data on the initial treatment. Results A total of 93 out of 145 eligible SAH patients participated in the study (62 females). A total of 41% (38/93) of subjects indicated burdensome headache at follow-up (mean 32.6 ± 9.3 months). Comparison between patients with (HA+) and without long-term headache (HA-) revealed significantly younger mean age (47.9 ± 11.8 vs. 55.6 ± 10.3 years; p < .01) as well as more favorable neurological conditions (WFNS I/II: 95% vs. 75%; p = .03) in HA+ cases. The mean average headache of the HA+ group was 3.7 ± 2.3 (10-point numeric rating scale), and the mean maximum headache intensity was 5.7 ± 2.9. Pain and HR-QOL scores demonstrated profound alterations in HA+ compared to HA- patients. Conclusions Our results suggest that a considerable proportion of SAH patients suffers from burdensome headache even years after the hemorrhage. Moreover, long-term headache is associated with reduced HR-QOL in these cases. Electronic supplementary material The online version of this article (10.1007/s00701-020-04235-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Torge Huckhagel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Regine Klinger
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nils Ole Schmidt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Mader MM, Piffko A, Dengler NF, Ricklefs FL, Dührsen L, Schmidt NO, Regelsberger J, Westphal M, Wolf S, Czorlich P. Initial pupil status is a strong predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage. Sci Rep 2020; 10:4764. [PMID: 32179801 PMCID: PMC7076009 DOI: 10.1038/s41598-020-61513-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/27/2020] [Indexed: 11/30/2022] Open
Abstract
Prognosis of patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH) is only insufficiently displayed by current standard prognostic scores. This study aims to evaluate the role of pupil status for mortality prediction and provide improved prognostic models. Anonymized data of 477 aSAH patients admitted to our medical center from November 2010 to August 2018 were retrospectively analyzed. Identification of variables independently predicting in-hospital mortality was performed by multivariable logistic regression analysis. Final regression models included Hunt & Hess scale (H&H), pupil status and age or in a simplified variation only H&H and pupil status, leading to the design of novel H&H-Pupil-Age score (HHPA) and simplified H&H-Pupil score (sHHP), respectively. In an external validation cohort of 402 patients, areas under the receiver operating characteristic curves (AUROC) of HHPA (0.841) and sHHP (0.821) were significantly higher than areas of H&H (0.794; p < 0.001) or World Federation of Neurosurgical Societies (WFNS) scale (0.775; p < 0.01). Accordingly, including information about pupil status improves the predictive performance of prognostic scores for in-hospital mortality in patients with aSAH. HHPA and sHHP allow simple, early and detailed prognosis assessment while predictive performance remained strong in an external validation cohort suggesting adequate generalizability and low interrater variability.
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Affiliation(s)
- Marius M Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany. .,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, 265 Campus Drive, Stanford, CA, 94305, USA.
| | - Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nora F Dengler
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nils O Schmidt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Czorlich P, Krätzig T, Kluge N, Skevas C, Knospe V, Spitzer MS, Dreimann M, Mende KC, Westphal M, Eicker SO. Intraocular pressure during neurosurgical procedures in context of head position and loss of cerebrospinal fluid. J Neurosurg 2019; 131:271-280. [PMID: 30141760 DOI: 10.3171/2018.3.jns173098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Perioperative visual loss (POVL) is a rare but serious complication in surgical disciplines, especially in spine surgery. The exact pathophysiology of POVL remains unclear, but elevated intraocular pressure (IOP) is known to be part of it. As POVL is rarely described in patients undergoing intracranial or intradural surgery, the aim of this study was to investigate the course of IOP during neurosurgical procedures with opening of the dura mater and loss of CSF. METHODS In this prospective, controlled trial, 64 patients fell into one of 4 groups of 16 patients each. Group A included patients undergoing spine surgery in the prone position, group B patients had intracranial procedures in the prone position, and group C patients were treated for intracranial pathologies in a modified lateral position with the head rotated. In groups A-C, the dura was opened during surgery. Group D patients underwent spine surgeries in the prone position with an intact dura. IOP was measured continuously pre-, peri-, and postoperatively. RESULTS In all groups, IOP decreased after induction of anesthesia and increased time dependently after final positioning for the operation. The maximum IOP in group A prior to opening of the dura was 28.6 ± 6.2 mm Hg and decreased to 23.44 ± 4.9 mm Hg directly after dura opening (p < 0.0007). This effect lasted for 30 minutes (23.5 ± 5.6 mm Hg, p = 0.0028); after 60 minutes IOP slowly increased again (24.5 ± 6.3 mm Hg, p = 0.15). In group B, the last measured IOP before CSF loss was 28.1 ± 5.0 mm Hg and decreased to 23.5 ± 6.1 mm Hg (p = 0.0039) after dura opening. A significant IOP decrease in group B lasted at 30 minutes (23.6 ± 6.0 mm Hg, p = 0.0039) and 60 minutes (23.7 ± 6.0 mm Hg, p = 0.0189). In group C, only the lower eye showed a decrease in IOP up to 60 minutes after loss of CSF (opening of dura, p = 0.0007; 30 minutes, p = 0.0477; 60 minutes, p = 0.0243). In group D (control group), IOP remained stable throughout the operation after the patient was prone. CONCLUSIONS This study is the first to demonstrate that opening of the dura with loss of CSF during neurosurgical procedures results in a decrease in IOP. This might explain why POVL predominantly occurs in spinal but rarely in intracranial procedures, offers new insight to the pathophysiology of POVL, and provides the basis for further research and treatment of POVL.German Clinical Trials Register (DRKS) no.: DRKS00007590 (drks.de).
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Affiliation(s)
| | | | | | | | | | | | - Marc Dreimann
- 3Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Burkhardt T, Czorlich P, Mende KC, Treitz A, Kiefmann R, Westphal M, Schmidt NO. Postoperative Nausea and Vomiting Following Craniotomy: Risk Factors and Complications in Context of Perioperative High-dose Dexamethasone Application. J Neurol Surg A Cent Eur Neurosurg 2019; 80:381-386. [DOI: 10.1055/s-0039-1685194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction Postoperative nausea and vomiting (PONV) is common in patients after craniotomy and may lead to severe postoperative complications. The aim of this study was to identify risk factors and postoperative complications associated with PONV in the context of perioperative high-dose dexamethasone administration.
Patients and Methods In this prospective single-center study, all patients planned for elective craniotomy for supra- and infratentorial lesions were eligible to be included. Any PONV in a 24-hour period after craniotomy was recorded and analyzed with regard to time to postoperative complications and the administration of perioperatively administered high-dose dexamethasone.
Results The overall PONV rate of 421 patients during a 9-month period was 18.1% (76 patients). Multivariate analysis revealed a significant association of PONV with female sex, infratentorial localization, age, and history of PONV. There was no association between PONV and postoperative complications such as intracranial hemorrhage, cerebrospinal fluid (CSF) leaks, or pneumonia. Perioperative administration of high-dose dexamethasone for prophylactic prevention of edema was the only significant risk factor for postoperative complications (odds ratio [OR]: 3.34; confidence interval [CI], 1.39–8.05; p < 0.01) with a highly significant association with the occurrence of CSF leaks (OR: 6.85; CI, 1.62–29.05; p < 0.01).
Conclusion The low PONV rate of 18.1% in this study may be the result of the frequent perioperative administration of high-dose dexamethasone for the prevention of edema. Our data indicate that perioperative high-dose dexamethasone is significantly associated with CSF leaks and can therefore not be recommended on a regular basis.
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Affiliation(s)
- Till Burkhardt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurosurgery, Friedrich-Ebert-Hospital, Neumünster, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Christian Mende
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annika Treitz
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Kiefmann
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils Ole Schmidt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Emami P, Czorlich P, Fritzsche FS, Westphal M, Rueger JM, Lefering R, Hoffmann M. Observed versus expected mortality in pediatric patients intubated in the field with Glasgow Coma Scale scores < 9. Eur J Trauma Emerg Surg 2019; 45:769-776. [PMID: 30631886 DOI: 10.1007/s00068-018-01065-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 12/26/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE A Glasgow Coma Scale (GCS) score of 8 or less in patients suffering from severe traumatic brain injury (TBI) represents a decision-making marker in terms of intubation. This study evaluated the impact of prehospital intubation on the mortality of these TBI cases among different age groups. METHODS This study included the data from patients predominantly suffering from severe TBI [Abbreviated Injury Scale (AIS) of the head ≥ 3, GCS score < 9, Injury Severity Score (ISS) > 9] who were registered in TraumaRegister DGU® from 2002 to 2013. An age-related analysis of five subgroups was performed (1-6, 7-15, 16-55, 56-79, and ≥ 80 years old). The observed and expected mortality were matched according to the Revised Injury Severity Classification, version II. RESULTS A total of 21,242 patients were included. More often, the intubated patients were severely injured when compared to the non-intubated patients (median ISS 29, IQR 22-41 vs. 24, IQR 16-29, respectively), with an associated higher mortality (42.2% vs. 30.0%, respectively). When compared to the calculated expected mortality, the observed mortality was significantly higher among the intubated patients within the youngest subgroup (42.2% vs. 33.4%, respectively; p = 0.03). CONCLUSIONS The observed mortality in the intubated children 1-6 years old suffering from severe TBI seemed to be higher than expected. Whether or not a GCS score of 8 or less is the only reliable criterion for intubation in this age group should be investigated in further trials.
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Affiliation(s)
- Pedram Emami
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany.
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany
| | - Friederike S Fritzsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany
| | - Johannes M Rueger
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Ostmerheimerstrasse 200, 51109, Cologne, Germany
| | - Michael Hoffmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Mader MMD, Czorlich P, König C, Fuhrmann V, Kluge S, Westphal M, Grensemann J. Intrathecal penetration of meropenem and vancomycin administered by continuous infusion in patients suffering from ventriculitis-a retrospective analysis. Acta Neurochir (Wien) 2018; 160:2099-2105. [PMID: 30242495 DOI: 10.1007/s00701-018-3680-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/12/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Vancomycin and meropenem are frequently used as empiric treatment for ventriculitis. Penetration into the cerebrospinal fluid (CSF) depends on various factors with a high inter-individual variability. Because attaining and maintaining adequate concentrations of meropenem and vancomycin in the CSF is crucial for their bactericidal effect, we introduced a routine therapeutic drug monitoring (TDM) from CSF and serum for both antibiotics. We studied the antibiotic penetration into the CSF. METHODS Patient data including serum and CSF concentrations for meropenem and vancomycin were collected in a retrospective fashion. Antibiotic CSF penetration ratio was calculated for each patient. Antibiotics were administered by continuous infusion aiming for serum target concentrations of 20-30 mg/L for vancomycin and 16-32 mg/L for meropenem. RESULTS Twenty-two patients with 36 CSF/serum pairs for meropenem and 43 pairs for vancomycin were studied. No patient suffered from renal or liver insufficiency. Mean vancomycin serum concentration was 22 ± 8 mg/L and the mean CSF concentration 4.5 ± 2.6 mg/L. CSF penetration was 20 ± 11% (coefficient of determination (R2) 0.02). For meropenem, the mean serum concentration was 30.7 ± 14.9 mg/L, mean CSF concentration 5.5 ± 5.2 mg/L, and a penetration of 18 ± 12%, R2 = 0.42. CONCLUSION Penetration of meropenem and vancomycin into the CSF is low while showing a high interindividual variability. Various patients in our study cohort were at risk for insufficient target attainment in CSF. Continuous administration of antibiotics under routine TDM appears to be a feasible and reasonable approach for optimization of intrathecal drug levels in patients suffering from ventriculitis. TDM might guide individual dosing adaptation and efforts to predict the CSF penetration of meropenem and vancomycin in cases of ventriculitis.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christina König
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Sauvigny T, Mohme M, Grensemann J, Dührsen L, Regelsberger J, Kluge S, Schmidt NO, Westphal M, Czorlich P. Rate and risk factors for a hyperactivity delirium in patients with aneurysmal subarachnoid haemorrhage. Neurosurg Rev 2018; 42:481-488. [DOI: 10.1007/s10143-018-0990-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/21/2018] [Accepted: 05/30/2018] [Indexed: 11/30/2022]
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Appel D, Seeberger M, Schwedhelm E, Czorlich P, Goetz AE, Böger RH, Hannemann J. Asymmetric and Symmetric Dimethylarginines are Markers of Delayed Cerebral Ischemia and Neurological Outcome in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2018; 29:84-93. [DOI: 10.1007/s12028-018-0520-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Sauvigny T, Göttsche J, Czorlich P, Vettorazzi E, Westphal M, Regelsberger J. Intracranial pressure in patients undergoing decompressive craniectomy: new perspective on thresholds. J Neurosurg 2018; 128:819-827. [DOI: 10.3171/2016.11.jns162263] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVEDecompressive craniectomy (DC) is an established part of treatment in patients suffering from malignant infarction of the middle cerebral artery (MCA) or traumatic brain injury (TBI). However, no clear evidence for intracranial pressure (ICP)-guided therapy after DC exists. The lack of this evidence might be due to the frequently used, but simplified threshold for ICP of 20 mm Hg, which determines further therapy. Therefore, the objective of this study was to evaluate this threshold's accuracy and to investigate the course of ICP values with respect to neurological outcome.METHODSData on clinical characteristics and parameters of the ICP course on the intensive care unit were collected retrospectively in 102 patients who underwent DC between December 2007 and April 2014 at the authors' institution. The postoperative ICP course in the first 168 hours was recorded and analyzed. From these findings, ICP thresholds discriminating favorable from unfavorable outcome were calculated using conditional inference tree analysis. Additionally, survival analysis was performed using the Kaplan-Meier method. Prognostic factors were assessed via univariate analysis and multivariate logistic regression. Favorable outcome was defined as a score of 0–4 on the modified Rankin Scale.RESULTSMultivariate logistic regression revealed that anisocoria, diagnosis, and ICP values differed significantly between the outcome groups. ICP values in the favorable and unfavorable outcome groups differed significantly (p < 0.001), while the mean ICP of both groups lay below the limit of 20 mm Hg (17.5 and 11.5 mm Hg, respectively). These findings were reproduced when analyzing the underlying pathologies of TBI and MCA infarction separately. Based on these findings, optimized time-dependent threshold values were calculated and found to be between 10 and 17 mm Hg. These values significantly distinguished favorable from unfavorable outcome and predicted 30-day mortality (p < 0.001).CONCLUSIONSThis study systematically evaluated ICP levels in a long-term analysis after DC and provides new, surprisingly low, time-dependent ICP thresholds for these patients. Future trials investigating the benefit of ICP-guided therapy should take these thresholds into consideration and validate them in further patient cohorts.
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Affiliation(s)
| | | | | | - Eik Vettorazzi
- 2Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Lefering R, Czorlich P. In Reply to the Letter to the Editor "Body Mass Index >35 as Independent Predictor of Mortality in Severe Traumatic Brain Injury: Statistical and Methodologic Issues". World Neurosurg 2017; 109:509. [PMID: 29232816 DOI: 10.1016/j.wneu.2017.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer, Cologne, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Mende KC, Gelderblom M, Schwarz C, Czorlich P, Schmidt NO, Vettorazzi E, Regelsberger J, Westphal M, Abboud T. Somatosensory evoked potentials in patients with high-grade aneurysmal subarachnoid hemorrhage. Neurosurg Focus 2017; 43:E17. [PMID: 29088953 DOI: 10.3171/2017.7.focus17427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this prospective study was to investigate the value of somatosensory evoked potentials (SEPs) in predicting outcome in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH). METHODS Between January 2013 and January 2015, 48 patients with high-grade SAH (Hunt and Hess Grade III, IV, or V) who were admitted within 3 days after hemorrhage were enrolled in the study. Right and left median and tibial nerve SEPs were recorded on Day 3 after hemorrhage and recorded again 2 weeks later. Glasgow Outcome Scale (GOS) scores were determined 6 months after hemorrhage and dichotomized as poor (Scores 1-3) or good (Scores 4-5). Results of SEP measurements were dichotomized (present or missing cortical responses or normal or prolonged latencies) for each nerve and side. These variables were summed and tested using logistic regression and a receiver operating characteristic curve to assess the value of SEPs in predicting long-term outcome. RESULTS At the 6-month follow-up visit, 29 (60.4%) patients had a good outcome, and 19 (39.6%) had a poor outcome. The first SEP measurement did not correlate with clinical outcome (area under the curve [AUC] 0.69, p = 0.52). At the second measurement of median nerve SEPs, all patients with a good outcome had cortical responses present bilaterally, and none of them had bilateral prolonged latencies (p = 0.014 and 0.003, respectively). In tibial nerve SEPs, 7.7% of the patients with a good GOS score had one or more missing cortical responses, and bilateral prolonged latencies were found in 23% (p = 0.001 and 0.034, respectively). The second measurement correlated with the outcome regarding each of the median and tibial nerve SEPs and the combination of both (AUC 0.75 [p = 0.010], 0.793 [p = 0.003], and 0.81 [p = 0.001], respectively). CONCLUSIONS Early SEP measurement after SAH did not correlate with clinical outcome, but measurement of median and tibial nerve SEPs 2 weeks after a hemorrhage did predict long-term outcome in patients with high-grade SAH.
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Affiliation(s)
| | | | | | | | | | - Eik Vettorazzi
- Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg; and
| | | | | | - Tammam Abboud
- Department of Neurosurgery, University Medical Center Göttingen, Germany
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Osterhage K, Czorlich P, Burkhardt TR, Rotermund R, Grzyska U, Flitsch J. Symptomatic Vasospasms as a Life-Threatening Complication After Transsphenoidal Surgery. World Neurosurg 2017; 110:180-188. [PMID: 29045853 DOI: 10.1016/j.wneu.2017.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 10/03/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify symptomatic vasospasms as a rare complication after transsphenoidal surgery, with emphasis on management and outcomes. METHODS In this retrospective study, the medical records of 1997 patients who underwent microscopic transsphenoidal surgery at our hospital between 2008 and 2016 were analyzed regarding postoperative vasospasm events, clinical management, and neurologic outcomes. RESULTS Four patients (0.2%) were identified who developed neurologic deficits in the postoperative phase caused by proven vasospasms due to subarachnoid hemorrhage (SAH). All 4 patients were treated according to current state-of-the-art recommendations for SAH-triggered vasospasms and, as ultima ratio, intra-arterial spasmolysis. Nonetheless, all patients developed multilocular ischemic infarctions. Three patients recovered with no or only slight neurologic deficits (2 with a Glasgow Outcome Score [GOS] of 5; 1 with a GOS of 4), and 1 patient died, at 24 days after surgery. CONCLUSIONS Although a rare complication, vasospasms after transsphenoidal surgery can lead to severe and multilocular ischemic infarctions with a wide variety of neurologic impairments. This rare complication should be considered in patients with unexpected postoperative neurologic deficits. Computed tomography (CT)/magnetic resonance imaging and (contrast-enhanced) CT/magnetic resonance angiography are appropriate diagnostic tools. Treatment of vasospasms, including the option of intra-arterial spasmolysis, should not be delayed.
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Affiliation(s)
- Katharina Osterhage
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till R Burkhardt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich Grzyska
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abboud T, Mende KC, Jung R, Czorlich P, Vettorazzi E, Priefler M, Kluge S, Westphal M, Regelsberger J. Prognostic Value of Early S100 Calcium Binding Protein B and Neuron-Specific Enolase in Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage: A Pilot Study. World Neurosurg 2017; 108:669-675. [PMID: 28943424 DOI: 10.1016/j.wneu.2017.09.074] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 09/11/2017] [Accepted: 09/13/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND This prospective study was undertaken to investigate the value of early S100 calcium binding protein B (S100B) and neuron-specific enolase (NSE) in prognosticating outcome in patients with poor-grade aneurysmal subarachnoid hemorrhage and to develop a statistical model and cutoff values for clinical practice. METHODS Between 2012 and 2014, patients with poor-grade subarachnoid hemorrhage (Hunt and Hess grade 3-5) who were admitted within 24 hours after hemorrhage were prospectively enrolled. Serum NSE and S100B levels were assayed once daily during the first 3 days after hemorrhage. Patient characteristics, Glasgow Coma Scale score, Hunt and Hess grade, and Fisher grade at admission were recorded. Glasgow Outcome Scale (GOS) score was obtained at 6 months and dichotomized as poor (score 1-3) or good (score 4-5). Logistic regression and receiver operating characteristic curve were used to assess the value of S100B and NSE in predicting outcome, and cutoff values were calculated using conditional interference trees. RESULTS The study included 52 patients. Hunt and Hess grade was 3 in 23 patients, 4 in 15 patients, and 5 in 14 patients. S100B range was 0.07-5.62 μg/L (mean 0.87 μg/L ± 1.06). NSE range was 5.7-94.2 μg/L (mean 16.1 μg/L ± 10.5). At 6-month follow-up, 23 patients (44.2%) had a poor outcome, and 29 patients (55.8%) had a good outcome. Both S100B at day 1 (P = 0.004; cutoff 0.202 μg/L) and NSE at day 1 (P = 0.047; cutoff 9.4 μg/L) predicted good outcome with a specificity of 100%. The specificity of mean S100B in detecting patients with poor outcome reached 100% (P = 0.003) when combined with mean NSE levels. CONCLUSIONS S100B and NSE measured during the first 3 days after hemorrhage showed, separately and combined, a significant predictive value in prognosticating clinical outcome in patients with poor-grade subarachnoid hemorrhage. A multicenter study with a large patient cohort is necessary to validate the above-mentioned cutoff values for clinical practice.
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Affiliation(s)
- Tammam Abboud
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; Department of Neurosurgery, University Medical Centre Göttingen, Göttingen, Germany.
| | - Klaus Christian Mende
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Jung
- Department of Clinical Chemistry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Marion Priefler
- Department of Intensive Care, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Czorlich P, Dreimann M, Emami P, Westphal M, Lefering R, Hoffmann M. Body Mass Index >35 as Independent Predictor of Mortality in Severe Traumatic Brain Injury. World Neurosurg 2017; 107:515-521. [PMID: 28823658 DOI: 10.1016/j.wneu.2017.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/28/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Severe traumatic brain injury (TBI) has a major influence on polytrauma outcome. The aim of this study was to evaluate the impact of body mass index (BMI) on mortality and early neurologic outcome in patients suffering from severe TBI with a special focus on obesity classes II and III (BMI ≥35). METHODS A retrospective cohort analysis of patients suffering from a leading, at least severe TBI and registered in the TraumaRegister DGU was conducted. Patients alive on admission with full status documentation on Glasgow Coma Scale, height, and weight were classified into 4 BMI subgroups. Early neurologic outcome was classified using the Glasgow Outcome Scale. RESULTS A total of 1634 patients met the inclusion criteria. Lowest mortality was documented for BMI group 1 (15.2%, BMI 25.0-29.9918.5). Highest mortality was found in BMI group 5 (25.6%, BMI ≥35). BMI ≥35 was an independent predictor of mortality with an odds ratio of 3.15 (95% confidence interval [1.06-9.36], P = 0.039). Further independent mortality predictors were >65 years of age, a Glasgow Coma Scale of ≤13, an Abbreviated Injury Scalehead ≥5, prehospital cardiopulmonary resuscitation, and a prehospital blood pressure of <90 mm Hg. In terms of good early neurologic outcomes, no differences were recorded between the BMI groups (range 59.0%-62.6%, P = 0.087). CONCLUSIONS In this study a BMI ≥35 is an independent predictor of mortality and is associated with an inferior early functional neurologic outcome.
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Affiliation(s)
- Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Marc Dreimann
- Division of Spine Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pedram Emami
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Michael Hoffmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, and Clinic for Orthopedics, Holstein, Germany
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Mohme M, Sauvigny T, Grensemann J, Söffker G, Kluge S, Westphal M, Czorlich P. Irreversible Total Loss of Brain Function and Organ Donation in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 105:492-497. [PMID: 28619501 DOI: 10.1016/j.wneu.2017.06.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening disease with an often fatal clinical course leading to irreversible loss of brain function (ILBF) (i.e., brain death). The purpose of this study was to assess the prevalence and characteristics of patients with aSAH who became organ donors after diagnosis of ILBF. METHODS Anonymized clinical data sets of 395 patients treated for aSAH at a university medical center from January 2011 to December 2016 were retrospectively analyzed. Prevalence of consent for organ donation and clinical characteristics, including parameters for diagnosis of irreversible loss of brain function, were assessed. RESULTS After initial admission to the intensive care unit, 18.0% of patients (n = 71) died (Glasgow Outcome Scale score 1). Intracerebral hemorrhage occurred in 42.3% of patients who died, aneurysmal rebleeding occurred in 19.7%, and intraventricular hemorrhage occurred in 87.3%. In 50.7% of patients who died (n = 36), ILBF was diagnosed, and 32.4% (n = 23) of these patients became organ donors. In 55.6%, additional diagnostic electroencephalography was performed. Male patients significantly more often became organ donors than female patients (P = 0.008). ILBF with subsequent organ donation was predominantly seen in patients <60 years old. A total 85 of organs were explanted for donation, including 42 kidneys, 21 livers, 3 pancreas, 11 hearts and 8 lungs. CONCLUSIONS ILBF in the setting of fatal aSAH is a prevalent diagnosis with complex demands for neurointensive care physicians. We demonstrated the clinical characteristics and epidemiologic factors of patients with aSAH converting to organ donors.
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Affiliation(s)
- Malte Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerold Söffker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Dreimann M, Hempfing A, Stangenberg M, Viezens L, Weiser L, Czorlich P, Eicker SO. Posterior vertebral column resection with 360-degree osteosynthesis in osteoporotic kyphotic deformity and spinal cord compression. Neurosurg Rev 2017; 41:221-228. [PMID: 28281189 DOI: 10.1007/s10143-017-0840-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/24/2017] [Accepted: 02/27/2017] [Indexed: 10/20/2022]
Abstract
Osteoporotic fractures with severe kyphosis and neurologic deficits often require decompression and stabilisation. To reduce the risk of procedure-related complications, single-stage posterolateral vertebrectomy and a 360-degree fusion can be performed. An adequate reduction of kyphotic deformity through this approach has not been reported. The aim of this study is to investigate the efficacy of kyphotic deformity reduction by this approach in osteoporotic situation. A retrospective analysis and chart review was performed for 10 consecutive patients who underwent posterolateral decompression and posterior vertebrectomy with dorsal mesh stabilisation and reduction of kyphotic deformity. Preoperative back pain was 8.6 on a visual analogue scale; it was reduced to 5.5 at discharge and 3.7 at the latest follow-up (18 months). The Frankel score improved from D to E (three patients) or was equal (E). Radiological segmental kyphosis was corrected from a mean of 25° to 5° (p < 0.008) postoperatively with a loss of 3° at follow-up (p < 0.005). Single-stage posterolateral vertebrectomy allow for a fast and safe reconstitution/preservation of neurological function in patients with osteoporotic fracture and kyphotic deformity. A significant correction of often-accompanied hyperkyphosis is possible without neurological deterioration and with an improved sagittal profile and good pain reduction.
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Affiliation(s)
- Marc Dreimann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany.
| | | | - Martin Stangenberg
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany
| | - Lennart Viezens
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany
| | - Lukas Weiser
- Department of Trauma, Orthopedic and Reconstructive Surgery, University Hospital Göttingen, Göttingen, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Sven Oliver Eicker
- Department of Neurosurgery, University Hospital Hamburg Eppendorf, Hamburg, Germany
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Czorlich P, Sauvigny T, Ricklefs F, Abboud T, Nierhaus A, Vettorazzi E, Reuter DA, Regelsberger J, Westphal M, Schmidt NO. Impact of dexamethasone in patients with aneurysmal subarachnoid haemorrhage. Eur J Neurol 2017; 24:645-651. [DOI: 10.1111/ene.13265] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 01/11/2017] [Indexed: 11/27/2022]
Affiliation(s)
- P. Czorlich
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - T. Sauvigny
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - F. Ricklefs
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - T. Abboud
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - A. Nierhaus
- Department of Intensive Care Medicine; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - E. Vettorazzi
- Department of Medical Biometry and Epidemiology; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - D. A. Reuter
- Department of Anaesthesiology; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - J. Regelsberger
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - M. Westphal
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
| | - N. O. Schmidt
- Department of Neurosurgery; University Medical Center Hamburg − Eppendorf; Hamburg Germany
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Abboud T, Rustom J, Bester M, Czorlich P, Vittorazzi E, Pinnschmidt HO, Westphal M, Regelsberger J. Morphology of Ruptured and Unruptured Intracranial Aneurysms. World Neurosurg 2016; 99:610-617. [PMID: 28017741 DOI: 10.1016/j.wneu.2016.12.053] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND In addition to size and location, the morphology of intracranial aneurysms has been proposed to predict rupture. This study was undertaken to compare morphologic features between ruptured and unruptured aneurysms and identify those associated with greater risk of rupture. METHODS Between 2010 and 2014, 301 patients with subarachnoid hemorrhage and 204 with unruptured aneurysms were admitted to our hospital. Two investigators reviewed 3-dimensional angiograms of all aneurysms. Risk factors for rupture were identified. Morphology was classified into single-sac aneurysms with smooth margin, single-sac aneurysms with irregular margin, aneurysms with a daughter sac, and multilobulated aneurysms. The value of morphology in predicting rupture was tested with the use of logistic regression. RESULTS A total of 420 aneurysms met the inclusion criteria. Multilobulated aneurysm was the most frequent finding among ruptured aneurysms, followed by single sac with irregular margin, aneurysm with daughter sac, and single sac with smooth margin (44.9%, 25.9%, 18%, and 11.2%, respectively). Among unruptured aneurysms, single sac with smooth margin was the most frequent finding, followed by single sac with irregular margin, multilobulated aneurysm, and aneurysm with daughter sac (38.1%, 29.8%, 20.9%, and 11.2%, respectively). Morphology was an independent predictor of rupture (receiver operating characteristic-area under the curve 0.693, P < 0.001). Risk of rupture increased by factor of 3 (5, 95% confidence interval [CI] 1.6-5.3) from single sac with regular margin to irregular margin, by factor of 5.5 (5, 95% CI 2.8-11.0) to daughter sac, and by factor of 7.3 (5, 95% CI 4.1-13.1) to multilobulated aneurysm. CONCLUSIONS Morphology might have an independent predictive value of aneurysm rupture. Risk of rupture might increase according to extent of morphologic change. Prospective studies will be necessary to evaluate the influence of aneurysm morphology on natural history.
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Affiliation(s)
- Tammam Abboud
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jihad Rustom
- Department of Internal Medicine, Klinikum Itzehoe, Itzehoe, Germany
| | - Maxim Bester
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vittorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Dreimann M, Hoffmann M, Viezens L, Weiser L, Czorlich P, Eicker SO. Reducing kyphotic deformity by posterior vertebral column resection with 360° osteosynthesis in metastatic epidural spinal cord compression (MESCC). Eur Spine J 2016; 26:113-121. [PMID: 27730422 DOI: 10.1007/s00586-016-4805-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 08/27/2016] [Accepted: 10/03/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Metastatic epidural spinal cord compression (MESCC) often requires anterior-posterior decompression and stabilization. To reduce approach-related complications, single-stage posterolateral vertebrectomy and 360° fusion is often performed. However, a sufficient reduction of kyphotic deformity through this approach has not been reported. The purpose of this study is to investigate the efficacy of kyphotic deformity reduction by this approach in MESCC. METHODS A retrospective analysis and chart review was performed for 14 consecutive patients who underwent a vertebrectomy and decompression from a posterolateral approach. Anterior mesh stabilization of the ventral column is used as hypomochlion for the posterior compression manoeuvre, which leads to reduction of the kyphotic deformity. RESULTS Pre-operative back pain was 7.2 on a visual analogue scale. Back pain was reduced to 4.4 at discharge and 2.0 at the latest follow-up with a mean follow-up of 12 months (p < 0.001). The Frankel score remains constant or improved from D to E. Radiological segmental kyphosis was corrected from a mean of 16° to 4° (p < 0.001) post-operatively with a loss of 3° at the final follow-up, but still with significant corrections compared with the pre-operative measurements (p < 0.003). CONCLUSION Single-stage posterolateral vertebrectomy and reconstruction is a safe and less invasive approach that allows a sufficient reduction of hyperkyphosis and preservation of neurological function in patients with MESCC. This approach is an efficient alternative to anterior-posterior fusion with good pain reduction and improved sagittal profile.
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Affiliation(s)
- Marc Dreimann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Michael Hoffmann
- Department of Orthopaedic and Trauma Surgery, Schön Klinik, Neustadt in Holstein, Germany
| | - Lennart Viezens
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Lukas Weiser
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Sven Oliver Eicker
- Department of Neurosurgery, University Hospital Hamburg Eppendorf, Hamburg, Germany
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Wolff M, Czorlich P, Nagaraj C, Schnöbel-Ehehalt R, Li Y, Kwapiszewska G, Olschewski H, Heschl S, Olschewski A. Amitriptyline and carbamazepine utilize voltage-gated ion channel suppression to impair excitability of sensory dorsal horn neurons in thin tissue slice: An in vitro study. Neurosci Res 2016; 109:16-27. [DOI: 10.1016/j.neures.2016.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/15/2016] [Accepted: 02/18/2016] [Indexed: 11/27/2022]
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Czorlich P, Skevas C, Knospe V, Vettorazzi E, Westphal M, Regelsberger J. Terson's syndrome - Pathophysiologic considerations of an underestimated concomitant disease in aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2016; 33:182-186. [PMID: 27452126 DOI: 10.1016/j.jocn.2016.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/28/2016] [Accepted: 04/02/2016] [Indexed: 10/21/2022]
Abstract
Terson syndrome (TS) is a common and underestimated concomitant disease in patients suffering from subarachnoid hemorrhage (SAH). Aim of this study was to evaluate the influence of an initial unconsciousness and raised intracranial pressure (ICP) on the development of TS. We performed a retrospective analysis of 213 prospective collected SAH patients screened for TS to investigate the impact of an initial unconsciousness and raised ICP on the development of TS. A univariate analysis followed by a multivariate logistic regression model was performed to identify risk factors that are associated with TS. The findings are all discussed and correlated with the present pathophysiologic considerations of TS. The rate of TS in this study was 23.9%. A higher risk of TS in the univariate analysis was associated with a Glasgow Coma scale⩽7 (p=0.001), higher Hunt and Hess grade (p=0.001), Fisher grade IV (p=0.002), intracerebral hemorrhage (p=0.011), initial unconsciousness (p=0.013) and an ICP of ⩾25mmHg (p<0.001). An ICP of ⩾25mmHg was the only independent predictor for TS in the multivariate analysis (p=0.007). TS patients had a higher mortality (p=0.012) and a higher risk for a worse long-term outcome (p=0.002). Notable that 5 of 51 TS patients (9.8%) in this study developed TS with no raised ICP or initial unconsciousness. Terson syndrome is a common concomitant disease in SAH patients. The pathomechanism leading to TS is not exclusively related to raised ICP levels and/or unconsciousness. However, these factors may be associated with a high percentage of TS.
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Affiliation(s)
- Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany.
| | - Christos Skevas
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Volker Knospe
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
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Emami P, Czorlich P, Fritzsche FS, Westphal M, Rueger JM, Lefering R, Hoffmann M. Impact of Glasgow Coma Scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury: a retrospective, multicenter cohort study. J Neurosurg 2016; 126:760-767. [PMID: 27035177 DOI: 10.3171/2016.1.jns152385] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Prediction of death and functional outcome is essential for determining treatment strategies and allocation of resources for patients with severe traumatic brain injury (TBI). The aim of this study was to evaluate, by using pupillary status and Glasgow Coma Scale (GCS) score, if patients with severe TBI who are ≤ 15 years old have a lower mortality rate and better outcome than adults with severe TBI. METHODS A retrospective cohort analysis of patients suffering from severe TBI registered in the Trauma Registry of the German Society for Trauma Surgery between 2002 and 2013 was undertaken. Severe TBI was defined as an Abbreviated Injury Scale of the head (AIShead) score of ≥ 3 and an AIS score for any other part of the body that does not exceed the AIShead score. Only patients with complete data (GCS score, age, and pupil parameters) were included. To assess the impact of GCS score and pupil parameters, the authors also used the recently introduced Eppendorf-Cologne Scale and divided the study population into 2 groups: children (0-15 years old) and adults (16-55 years old). Each patient's outcome was measured at discharge from the trauma center by using the Glasgow Outcome Scale. RESULTS A total of 9959 patients fulfilled the study inclusion criteria; 888 (8.9%) patients were ≤ 15 years old (median 10 years). The overall mortality rate and the mortality rate for patients with a GCS of 3 and bilaterally fixed and dilated pupils (19.9% and 16.3%, respectively) were higher for the adults than for the pediatric patients (85% vs 80.9%, respectively), although cardiopulmonary resuscitation rates were significantly higher in the pediatric patients (5.6% vs 8.8%, respectively). In the multivariate logistic regression analysis, no motor response (OR 3.490, 95% CI 2.240-5.435) and fixed pupils (OR 4.197, 95% CI 3.271-5.386) and bilateral dilated pupils (OR 2.848, 95% CI 2.282-3.556) were associated with a higher mortality rate. Patients ≤ 15 years old had a statistically lower mortality rate (OR 0.536, 95% CI 0.421-0.814; p = 0.001). The rate of good functional outcomes (Glasgow Outcome Scale Score 4 or 5) was higher in pediatric patients than in the adults (72.2% vs 63.1%, respectively). CONCLUSIONS This study found that severe TBI in children aged ≤ 15 years is associated with a lower mortality rate and superior functional outcome than in adults. Also, children admitted with a missing motor response or fixed and bilaterally dilated pupils also have a lower mortality rate and higher functional outcome than adults with the same initial presentation. Therefore, patients suffering from severe TBI, especially pediatric patients, could benefit from early and aggressive treatment.
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Affiliation(s)
| | | | | | | | - Johannes M Rueger
- Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg; and
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Michael Hoffmann
- Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg; and
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Czorlich P, Sauvigny T, Ricklefs F, Kluge S, Vettorazzi E, Regelsberger J, Westphal M, Schmidt NO. The simplified acute physiology score II to predict hospital mortality in aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2015; 157:2051-9. [PMID: 26467798 DOI: 10.1007/s00701-015-2605-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/05/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early prediction of increased morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH) remains crucial to improving patient management. Most prediction models lack external validation and focus on disease-specific items without considering physiological parameters and the past medical history. The aim was to assess the validity of the established Simplified Acute Physiology Score II (SAPS-II) in an aSAH cohort for the prediction of hospital mortality and to identify additional physiological and clinical predictors. METHODS The predictive value of SAPS-II for hospital mortality was assessed in a retrospective analysis of 263 consecutive patients with aSAH. Additional physiological and clinical parameters including the past medical history were analyzed by forward selection multivariate analysis to identify independent predictors of hospital mortality and to improve the prediction model. RESULTS The SAPS-II predicted hospital mortality with an area under the curve (AUC) of 0.834 with an odds ratio (OR) of 1.097 [95 % confidence interval 1.067-1.128) for each additional point. Forward selection multivariate analysis identified the Glasgow Coma Scale score (P < 0.001), history of chronic headache (P = 0.01) and medication with anticoagulants (P = 0.04) as independent predictors of hospital mortality. Adding these parameters to the SAPS-II, the AUC increased to 0.86. CONCLUSION This study validates the predictive accuracy of SAPS-II for hospital mortality in aSAH patients. Additional parameters from the past medical history increase its predictive power. From a practical viewpoint, SAPS-II alone already represents a sufficient and powerful score to predict hospital mortality at an early time point and may help to improve patient management.
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Affiliation(s)
- Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Franz Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Nils Ole Schmidt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Czorlich P, Regelsberger J, Meixensberger J, Westphal M, Eicker SO. From Abstract to Publication in a Peer-Reviewed Journal: Evaluation of the 63rd Annual Meeting of the German Society of Neurosurgery. J Neurol Surg A Cent Eur Neurosurg 2015; 77:46-51. [PMID: 26444960 DOI: 10.1055/s-0035-1558822] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The presentation and academic discussion of the latest scientific research is the central purpose of meetings like the annual meeting of the German Society of Neurosurgery (DGNC). The aim of this study was to investigate the publication rate of all oral and poster abstracts of the DGNC meeting 2012 held in Leipzig, Germany, in peer-reviewed journals and to identify factors that are associated with a higher publication rate. MATERIAL AND METHODS We reviewed all accepted oral and poster presentations of the meeting. Then a search in PubMed was performed to determine the publication rate within 3 years after the abstract submission deadline. We used the information to identify factors associated with a higher publication rate. RESULTS The publication rate in a peer-reviewed journal was 40.4% for all presented abstracts. Overall, 41.5% of all poster presentations and 40.1% of all oral presentations were published within 3 years. Abstracts presenting prospective studies or university research had a statistically higher chance of publication. The average journal impact factor for all published abstracts was 2.99, and 81 different journals were chosen for publication. CONCLUSIONS Overall, 40.4% of all presented abstracts at the 2012 DGNC were published in a peer-reviewed journal indexed in PubMed, which reflects the high scientific standard of this meeting. Prospective studies and studies presented by authors from universities had a higher chance of being published.
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Affiliation(s)
- Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sven Oliver Eicker
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Skevas C, Czorlich P, Knospe V, Stemplewitz B, Richard G, Westphal M, Regelsberger J, Wagenfeld L. Terson's Syndrome—Rate and Surgical Approach in Patients with Subarachnoid Hemorrhage. Ophthalmology 2014; 121:1628-33. [DOI: 10.1016/j.ophtha.2014.02.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 02/14/2014] [Accepted: 02/14/2014] [Indexed: 11/29/2022] Open
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