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Annoni F, Gouvea Bogossian E, Peluso L, Su F, Moreau A, Nobile L, Casu SG, Sterchele ED, Calabro L, Salvagno M, Oddo M, Taccone FS. Ketone Bodies after Cardiac Arrest: A Narrative Review and the Rationale for Use. Cells 2024; 13:784. [PMID: 38727320 PMCID: PMC11083685 DOI: 10.3390/cells13090784] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/27/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
Cardiac arrest survivors suffer the repercussions of anoxic brain injury, a critical factor influencing long-term prognosis. This injury is characterised by profound and enduring metabolic impairment. Ketone bodies, an alternative energetic resource in physiological states such as exercise, fasting, and extended starvation, are avidly taken up and used by the brain. Both the ketogenic diet and exogenous ketone supplementation have been associated with neuroprotective effects across a spectrum of conditions. These include refractory epilepsy, neurodegenerative disorders, cognitive impairment, focal cerebral ischemia, and traumatic brain injuries. Beyond this, ketone bodies possess a plethora of attributes that appear to be particularly favourable after cardiac arrest. These encompass anti-inflammatory effects, the attenuation of oxidative stress, the improvement of mitochondrial function, a glucose-sparing effect, and the enhancement of cardiac function. The aim of this manuscript is to appraise pertinent scientific literature on the topic through a narrative review. We aim to encapsulate the existing evidence and underscore the potential therapeutic value of ketone bodies in the context of cardiac arrest to provide a rationale for their use in forthcoming translational research efforts.
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Affiliation(s)
- Filippo Annoni
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Humanitas Gavazzeni Hospital, 24125 Bergamo, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | - Fuhong Su
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Anthony Moreau
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Leda Nobile
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Stefano Giuseppe Casu
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Elda Diletta Sterchele
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Lorenzo Calabro
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Michele Salvagno
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Mauro Oddo
- Medical Directorate for Research, Education and Innovation, Direction Médicale, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, 1011 Lausanne, Switzerland
| | - Fabio Silvio Taccone
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
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2
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Poblete RA, Yaceczko S, Aliakbar R, Saini P, Hazany S, Breit H, Louie SG, Lyden PD, Partikian A. Optimization of Nutrition after Brain Injury: Mechanistic and Therapeutic Considerations. Biomedicines 2023; 11:2551. [PMID: 37760993 PMCID: PMC10526443 DOI: 10.3390/biomedicines11092551] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Emerging science continues to establish the detrimental effects of malnutrition in acute neurological diseases such as traumatic brain injury, stroke, status epilepticus and anoxic brain injury. The primary pathological pathways responsible for secondary brain injury include neuroinflammation, catabolism, immune suppression and metabolic failure, and these are exacerbated by malnutrition. Given this, there is growing interest in novel nutritional interventions to promote neurological recovery after acute brain injury. In this review, we will describe how malnutrition impacts the biomolecular mechanisms of secondary brain injury in acute neurological disorders, and how nutritional status can be optimized in both pediatric and adult populations. We will further highlight emerging therapeutic approaches, including specialized diets that aim to resolve neuroinflammation, immunodeficiency and metabolic crisis, by providing pre-clinical and clinical evidence that their use promotes neurologic recovery. Using nutrition as a targeted treatment is appealing for several reasons that will be discussed. Given the high mortality and both short- and long-term morbidity associated with acute brain injuries, novel translational and clinical approaches are needed.
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Affiliation(s)
- Roy A. Poblete
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Shelby Yaceczko
- UCLA Health, University of California, 100 Medical Plaza, Suite 345, Los Angeles, CA 90024, USA;
| | - Raya Aliakbar
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Pravesh Saini
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Saman Hazany
- Department of Radiology, Keck School of Medicine, The University of Southern California, 1500 San Pablo Street, Los Angeles, CA 90033, USA;
| | - Hannah Breit
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Stan G. Louie
- Department of Clinical Pharmacy, School of Pharmacy, The University of Southern California, 1985 Zonal Avenue, Los Angeles, CA 90089, USA;
| | - Patrick D. Lyden
- Department of Neurology, Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA;
| | - Arthur Partikian
- Department of Neurology, Department of Pediatrics, Keck School of Medicine, The University of Southern California, 2010 Zonal Avenue, Building B, 3P61, Los Angeles, CA 90033, USA;
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3
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Coppler PJ. Implementing a strict fever control protocol for resuscitated cardiac arrest patients. Resuscitation 2023; 188:109841. [PMID: 37196805 DOI: 10.1016/j.resuscitation.2023.109841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Fernandez Hernandez S, Busl KM, Maciel CB. Hibernation as a path to recovery-is waiting worth the wait? When does improvement in neurologic function happen in survivors of cardiac arrest with an early poor exam? Resuscitation 2023; 188:109829. [PMID: 37178903 DOI: 10.1016/j.resuscitation.2023.109829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Affiliation(s)
| | - Katharina M Busl
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA, 32611; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA, 32611
| | - Carolina B Maciel
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA, 32611; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA, 32611; Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Department of Neurology, University of Utah, Salt Lake City, UT, USA, 84132.
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Mason Sharma A, Birnhak A, Sanborn E, Bhana N, Kazmi K, Thon JM, Thon OR, Siegler JE. Neuroimaging mimics of anoxic brain injury: A review. J Neuroimaging 2023. [PMID: 37070435 DOI: 10.1111/jon.13106] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 04/19/2023] Open
Abstract
Diffuse cortical diffusion changes on magnetic resonance imaging (MRI) are characteristically ascribed to global cerebral anoxia, typically after cardiac arrest. Far from being pathognomonic, however, this neuroimaging finding is relatively nonspecific, and can manifest in a myriad of disease states including hypoxia, metabolic derangements, infections, seizure, toxic exposures, and neuroinflammation. While these various conditions can all produce a neuroimaging pattern of widespread cortical diffusion restriction, many of these underlying causes do have subtly unique imaging features that are appreciable on MRI and can be of clinical and diagnostic utility. Specific populations of neurons are variably sensitive to certain types of injury, whether due to differences in perfusion, receptor type density, or the unique tropisms of infectious organisms. In this narrative review, we discuss a number of distinct etiologies of diffuse cortical diffusion restriction on MRI, the unique pathophysiologies responsible for tissue injury, and the resulting neuroimaging characteristics that can be of assistance in differentiating them. As widespread cortical injury from any cause often presents with altered mental status or coma, the differential diagnosis can be enhanced with rapid acquisition of MRI when clinical history or detailed physical examination is limited. In such settings, the distinct imaging features discussed in this article are of interest to both the clinician and the radiologist.
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Affiliation(s)
| | - Alana Birnhak
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
| | - Emma Sanborn
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - Nikhil Bhana
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
| | - Khuram Kazmi
- Department of Diagnostic Radiology, Cooper University Hospital, Camden, New Jersey, USA
| | - Jesse M Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
| | - Olga R Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
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Coppler PJ, Elmer J. Anti-seizure medicine treatment of post-anoxic myoclonus. Resuscitation 2023; 186:109773. [PMID: 36958630 DOI: 10.1016/j.resuscitation.2023.109773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 03/25/2023]
Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
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Steinberg A, Hudoba C, Hwang DY, Kramer NM, Mehta AK, Muehlschlegel S, Jones CA, Besbris J. Top Ten Tips Palliative Care Clinicians Should Know About Disorders of Consciousness: A Focus on Traumatic and Anoxic Brain Injury. J Palliat Med 2022; 25:1571-1578. [PMID: 35639356 DOI: 10.1089/jpm.2022.0202] [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] [Indexed: 11/13/2022] Open
Abstract
Palliative care (PC) teams commonly encounter patients with disorders of consciousness (DOC) following anoxic or traumatic brain injury (TBI). Primary teams may consult PC to help surrogates in making treatment choices for these patients. PC clinicians must understand the complexity of predicting neurologic outcomes, address clinical nihilism, and appropriately guide surrogates in making decisions that are concordant with patients' goals. The purpose of this article was to provide PC providers with a better understanding of caring for patients with DOC, specifically following anoxic or TBI. Many of the tips acknowledge the uncertainty of DOC and provide strategies to help tackle this dilemma.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christine Hudoba
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Neha M Kramer
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA.,Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Ambereen K Mehta
- Palliative Care Program, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Department of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Department of Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Christopher A Jones
- Department of Medicine and Palliative Care Program, Duke University Hospital, Durham, North Carolina, USA
| | - Jessica Besbris
- Department of Internal Medicine and Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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8
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Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
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9
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Sarma D, Tabi M, Jentzer JC. Society for Cardiovascular Angiography and Intervention Shock Classification Predicts Mortality After Out-of-Hospital Cardiac Arrest. Resuscitation 2022; 172:101-105. [PMID: 35122891 DOI: 10.1016/j.resuscitation.2022.01.025] [Citation(s) in RCA: 1] [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: 12/17/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Shock is common in patients resuscitated from out-of-hospital-cardiac arrest (OHCA). Shock severity can be classified using the Society for Cardiovascular Angiography and Intervention (SCAI) Shock Classification. We aimed to examine the association of SCAI Shock Stage with in-hospital mortality and neurological outcome in comatose OHCA patients undergoing targeted temperature management (TTM). METHODS This study included 213 comatose adult patients who underwent TTM after OHCA between January 2007 and December 2017. SCAI shock stage (A through E) was assigned using data from the first 24 hours, with shock defined as SCAI shock stage C/D/E. Good neurological outcome was defined as a modified Rankin Scale (mRS) less than 3. RESULTS In-hospital mortality was higher in the 144 (67.6%) patients with shock (46.5% v. 23.2%, unadjusted OR 2.88, 95% CI 1.51-5.51, p = 0.001). After multivariable adjustment, each SCAI shock stage was incrementally associated with an increased risk of in-hospital mortality (adjusted OR 1.80 per stage, 95% CI 1.20-2.71, p = 0.003). Good neurological outcome was less likely in patients with shock (31.9% vs. 53.6%, unadjusted OR 0.41, 95% CI 0.23-0.73, p = 0.002) and a higher SCAI shock stage was incrementally associated with a lower likelihood of good neurological outcome after multivariable adjustment (adjusted OR 0.67 per stage, 95% CI 0.48-0.93, p = 0.015). CONCLUSION Higher shock severity, defined using the SCAI Shock Classification, was associated with increased in-hospital mortality and a lower likelihood of good neurological outcome in OHCA patients treated with TTM.
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Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Meir Tabi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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10
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Qafiti FN, Rubay D, Shin R, Lottenberg L, Borrego R. Therapeutic Hypothermia With Progesterone Improves Neurologic Outcomes in Ventricular Fibrillation Cardiac Arrest After Electric Shock. Cureus 2021; 13:e15749. [PMID: 34290928 PMCID: PMC8289402 DOI: 10.7759/cureus.15749] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 11/24/2022] Open
Abstract
Trauma by electricity imposes mechanical, electrical, and thermal forces on the human body. Often, the delicate cardiac electrophysiology is disrupted causing dysrhythmia and subsequent cardiac arrest. Anoxic brain injury (ABI) is the most severe consequence and the main cause of mortality following cardiac arrest. Establishing a working protocol to treat patients who are at risk for ABI after suffering a cardiac arrest is of paramount importance. There has yet to be sufficient exploration of combination therapy of therapeutic hypothermia (TH) and progesterone as a neuroprotective strategy in patients who have suffered cardiac arrest after electric shock. The protocol required TH initiation upon transfer to the ICU with a target core body temperature of 33°C for 18 hours. This was achieved through a combination of cooling blankets, ice packs, chilled IV fluids, nasogastric lavage with iced saline, and intravascular cooling devices. Progesterone therapy at 80-100 mg intramuscularly every 12 hours for 72 hours was initiated shortly after admission to the ICU. We present a case series of three patients (mean age = 29.3 years, mean presenting Glasgow Coma Score = 3) who suffered ventricular fibrillation (VF) cardiac arrest from non-lightning electric shock, and who had considerably improved outcomes following the TH-progesterone combination therapy protocol. The average length of stay was 13.7 days. The cases presented suggest that there may be a role for neuroprotective combination therapy in post-resuscitation care of VF cardiac arrest. While TH is well documented as a neuroprotective measure, progesterone administration is a safe therapy with promising, albeit currently inconclusive, neuroprotective effect. Future protocols involving TH and progesterone combination therapy in these patients should be further explored.
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Affiliation(s)
- Fred N Qafiti
- General Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - David Rubay
- Trauma and Surgical Critical Care, University of Florida College of Medicine, Gainesville, USA
| | - Rebecca Shin
- Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Lawrence Lottenberg
- Surgery, St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, USA
| | - Robert Borrego
- Surgery, St. Mary's Medical Center, West Palm Beach, USA
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Zhang B, O’Brien K, Won W, Li S. A Retrospective Analysis on Clinical Practice-Based Approaches Using Zolpidem and Lorazepam in Disorders of Consciousness. Brain Sci 2021; 11:brainsci11060726. [PMID: 34072336 PMCID: PMC8226545 DOI: 10.3390/brainsci11060726] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 12/03/2022] Open
Abstract
This is a retrospective study to investigate the results of using zolpidem and lorazepam in persons with disorders of consciousness (DoC) and to provide practical information for clinical application and further studies. The cohort included 146 patients (11 hemorrhagic stroke, 87 traumatic brain injury (TBI), 48 anoxic brain injury (ABI)) admitted to a specialized DoC rehabilitation program. A positive trial indicated a patient responded to either zolpidem or lorazepam with prominent functional improvements necessitating routine use of the medication. Non-responders had equivocal or negative (i.e., went to sleep) responses. Eleven patients with a stroke who had either medication were all non-responders. Of the remaining 135 patients, 95 received at least one medication trial. The overall positive rate was 11.6% (11/95), with 6.3% (5/79) for zolpidem and 14.0% (6/43) for lorazepam. Among TBI patients, the positive rate of the zolpidem trial (10.2%, 5/49) was slightly higher than that of the lorazepam trial (6.9%, 2/29; p > 0.05). Among ABI patients, the positive rate of the lorazepam trial (28.6%, 4/14) was significantly higher than that of the zolpidem trial (0%, 0/30; p = 0.007). Following a positive trial, most patients were continued on the medications on a regular basis before eventual discontinuation. Our results suggested the etiology of DoC, considering traumatic vs. anoxic injuries, may serve in guiding the clinical application of these medications in the treatment of DoC and in future prospective studies. We advocate for screening all patients with DoC using zolpidem and/or lorazepam.
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Affiliation(s)
- Bei Zhang
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (B.Z.); (W.W.)
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Katherine O’Brien
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - William Won
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (B.Z.); (W.W.)
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (B.Z.); (W.W.)
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
- Correspondence:
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12
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George N, Lawler A, Leong I, Doshi AA, Guyette FX, Coppler PJ. Beyond Extracorporeal Cardiopulmonary Resuscitation: Systems of Care Supporting Cardiac Arrest Patients. PREHOSP EMERG CARE 2021; 26:189-194. [PMID: 33570453 DOI: 10.1080/10903127.2021.1889728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Out-of-hospital cardiac arrest (OHCA) is a major cause of death and disability in the United States. Cardiac arrest centers (CAC) are necessary for the management of these critically ill and complex post arrest patients due to their specialized services and provider expertise. We report the case of a patient with OHCA and the systems of care involved in his resuscitation and recovery. Case Report: Emergency medical services attended a 39-year-old male with ongoing bystander cardiopulmonary resuscitation (CPR) after a witnessed collapse. Despite receiving appropriate advanced cardiac life support, including three defibrillations, he remained in refractory ventricular fibrillation. A prehospital physician identified him as an extracorporeal cardiopulmonary resuscitation (ECPR) candidate due to his age, witnessed arrest, refractory rhythm, and functional status. He was expedited to a CAC but no longer qualified for ECPR due to the time limit. He was resuscitated by the multiple teams activated prior to his arrival. He eventually had sustained return of circulation, was taken to the catheterization lab for emergent percutaneous coronary intervention, and recovered with a good neurologic outcome. Conclusion: Cardiac arrest centers may be capable of advanced interventions including ECPR. However, the systems of care offered by these centers is itself a lifesaving intervention. As this case highlights, despite not receiving the specified intervention (ECPR) the systems of care required to offer such a resource led to this favorable outcome.
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13
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Ata F, Bint I Bilal A, Tajelsir Abdalla Osman O, Arif MA, Elhassan M, hamid T, Al Suwaidi J, Choudry H, Abushahba G. Reversible hypoxic-ischemic encephalopathy post prolonged out-of-hospital cardiac arrest: A case series. Clin Case Rep 2021; 9:1529-1533. [PMID: 33768882 PMCID: PMC7981696 DOI: 10.1002/ccr3.3820] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/29/2020] [Accepted: 01/05/2021] [Indexed: 11/13/2022] Open
Abstract
This article highlights the possibility of positive outcomes associated with prolonged CPR and anoxic brain injury contesting the idea that such patients will invariably end up in a persistent vegetative state.
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Affiliation(s)
- Fateen Ata
- Department of Internal MedicineHamad General HospitalHamad Medical CorporationDohaQatar
| | - Ammara Bint I Bilal
- Department of RadiologyHamad General HospitalHamad Medical CorporationDohaQatar
| | | | | | - Mawahib Elhassan
- Department of CardiologyHeart HospitalHamad Medical Corporation.DohaQatar
| | - Tahir hamid
- Department of CardiologyHeart HospitalHamad Medical Corporation.DohaQatar
| | - Jassim Al Suwaidi
- Department of CardiologyHeart HospitalHamad Medical Corporation.DohaQatar
| | - Hassan Choudry
- Pediatric GastroenterologyJohns Hopkins Medical InstituteBaltimoreMDUSA
| | - Galal Abushahba
- Department of CardiologyRoyal Lancaster Infirmary HospitalMorecambe UniversityLancasterUK
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14
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Coppler PJ, Callaway CW, Guyette FX, Baldwin M, Elmer J. Early risk stratification after resuscitation from cardiac arrest. J Am Coll Emerg Physicians Open 2020; 1:922-931. [PMID: 33145541 PMCID: PMC7593432 DOI: 10.1002/emp2.12043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 12/31/2019] [Revised: 02/12/2020] [Accepted: 02/18/2020] [Indexed: 01/08/2023] Open
Abstract
Emergency clinicians often resuscitate cardiac arrest patients, and after acute resuscitation, clinicians face multiple decisions regarding disposition. Recent evidence suggests that out-of-hospital cardiac arrest patients with return of spontaneous circulation have higher odds of survival to hospital discharge, long-term survival, and improved functional outcomes when treated at centers that can provide advanced multidisciplinary care. For community clinicians, a high volume cardiac arrest center may be hours away. While current guidelines recommend against neurological prognostication in the first hours or days after return of spontaneous circulation, there are early findings suggestive of irrecoverable brain injury in which the patient would receive no benefit from transfer. In this Concepts article, we describe a simplified approach to quickly evaluate neurological status in cardiac arrest patients and identify findings concerning for irrecoverable brain injury. Characteristics of the arrest and resuscitation, initial neurological assessment, and brain computed tomography together can identify patients with high likelihood of irrecoverable anoxic injury. Patients who may benefit from centers with access to continuous electroencephalography are discussed. This approach can be used to identify patients who may benefit from rapid transfer to cardiac arrest centers versus those who may benefit from care close to home. Risk stratification also can provide realistic expectations for recovery to families.
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Affiliation(s)
- Patrick J. Coppler
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Clifton W. Callaway
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Francis X. Guyette
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Maria Baldwin
- Department of NeurologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Jonathan Elmer
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
- Department of NeurologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
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15
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine (J.C.J.), Mayo Clinic, Rochester, MN.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine (J.C.J.), Mayo Clinic, Rochester, MN
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Canada (S.v.D.)
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital Health Network, Cincinnati, OH (T.D.H.)
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16
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Liu L, Yu W. Editorial: Multimodality Monitoring or Evaluation of Neuro-Function in Modern NICU. Front Neurol 2020; 10:1423. [PMID: 32116994 PMCID: PMC7010929 DOI: 10.3389/fneur.2019.01423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/30/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Liping Liu
- Department of Neurology and Stroke Center, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
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17
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Nguyen PL, Alreshaid L, Poblete RA, Konye G, Marehbian J, Sung G. Targeted Temperature Management and Multimodality Monitoring of Comatose Patients After Cardiac Arrest. Front Neurol 2018; 9:768. [PMID: 30254606 PMCID: PMC6141756 DOI: 10.3389/fneur.2018.00768] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/24/2018] [Indexed: 01/14/2023] Open
Abstract
Out-of-hospital cardiac arrest (CA) remains a leading cause of sudden morbidity and mortality; however, outcomes have continued to improve in the era of targeted temperature management (TTM). In this review, we highlight the clinical use of TTM, and provide an updated summary of multimodality monitoring possible in a modern ICU. TTM is neuroprotective for survivors of CA by inhibiting multiple pathophysiologic processes caused by anoxic brain injury, with a final common pathway of neuronal death. Current guidelines recommend the use of TTM for out-of-hospital CA survivors who present with a shockable rhythm. Further studies are being completed to determine the optimal timing, depth and duration of hypothermia to optimize patient outcomes. Although a multidisciplinary approach is necessary in the CA population, neurologists and neurointensivists are central in selecting TTM candidates and guiding patient care and prognostic evaluation. Established prognostic tools include clinal exam, SSEP, EEG and MR imaging, while functional MRI and invasive monitoring is not validated to improve outcomes in CA or aid in prognosis. We recommend that an evidence-based TTM and prognostication algorithm be locally implemented, based on each institution's resources and limitations. Given the high incidence of CA and difficulty in predicting outcomes, further study is urgently needed to determine the utility of more recent multimodality devices and studies.
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Affiliation(s)
- Peggy L Nguyen
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Laith Alreshaid
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Roy A Poblete
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Geoffrey Konye
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jonathan Marehbian
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Gene Sung
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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18
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Abstract
Pseudohypoxic brain swelling (or the more recent term, postoperative intracranial hypotension-associated venous congestion) is a rare and potentially deadly complication that can occur after routine spine or brain surgery. The mechanism of this injury has been described as a rapid cerebral spinal fluid drainage leading to venous cerebral congestion. The clinical and radiographic findings mimic those found in a patient who has suffered an anoxic brain injury. We present the third reported case of postoperative intracranial hypotension-associated venous congestion following spinal surgery.
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Affiliation(s)
| | - Derek Kroll
- Neurological Surgery, Advocate Bromenn Medical Center
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19
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Ishaque M, Manning JH, Woolsey MD, Franklin CG, Tullis EW, Beckmann CF, Fox PT. Functional integrity in children with anoxic brain injury from drowning. Hum Brain Mapp 2017; 38:4813-4831. [PMID: 28759710 DOI: 10.1002/hbm.23745] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 06/02/2016] [Revised: 07/10/2017] [Accepted: 07/15/2017] [Indexed: 01/10/2023] Open
Abstract
Drowning is a leading cause of accidental injury and death in young children. Anoxic brain injury (ABI) is a common consequence of drowning and can cause severe neurological morbidity in survivors. Assessment of functional status and prognostication in drowning victims can be extremely challenging, both acutely and chronically. Structural neuroimaging modalities (CT and MRI) have been of limited clinical value. Here, we tested the utility of resting-state functional MRI (rs-fMRI) for assessing brain functional integrity in this population. Eleven children with chronic, spastic quadriplegia due to drowning-induced ABI were investigated. All were comatose immediately after the injury and gradually regained consciousness, but with varying ability to communicate their cognitive state. Eleven neurotypical children matched for age and gender formed the control group. Resting-state fMRI and co-registered T1-weighted anatomical MRI were acquired at night during drug-aided sleep. Network integrity was quantified by independent components analysis (ICA), at both group- and per-subject levels. Functional-status assessments based on in-home observations were provided by families and caregivers. Motor ICNs were grossly compromised in ABI patients both group-wise and individually, concordant with their prominent motor deficits. Striking preservations of perceptual and cognitive ICNs were observed, and the degree of network preservation correlated (ρ = 0.74) with the per-subject functional status assessments. Collectively, our findings indicate that rs-fMRI has promise for assessing brain functional integrity in ABI and, potentially, in other disorders. Furthermore, our observations suggest that the severe motor deficits observed in this population can mask relatively intact perceptual and cognitive capabilities. Hum Brain Mapp 38:4813-4831, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Mariam Ishaque
- Research Imaging Institute, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Janessa H Manning
- Merrill Palmer Skillman Institute, Wayne State University, Detroit, Michigan
| | - Mary D Woolsey
- Research Imaging Institute, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Crystal G Franklin
- Research Imaging Institute, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Christian F Beckmann
- Department of Cognitive Neuroscience, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Donders Center for Cognitive Neuroimaging, Radboud University, Nijmegen, The Netherlands.,Centre for Functional MRI of the Brain, University of Oxford, Oxford, United Kingdom
| | - Peter T Fox
- Research Imaging Institute, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,South Texas Veterans Healthcare System, San Antonio, Texas.,Shenzhen University School of Medicine, Shenzhen, People's Republic of China
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20
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Affiliation(s)
- Carolina B Maciel
- Department of Neurology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
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21
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Affiliation(s)
- James P Battista
- Department of Neurology, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew S Robbins
- Department of Neurology, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, USA
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22
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Varotto G, Fazio P, Rossi Sebastiano D, Duran D, D'Incerti L, Parati E, Sattin D, Leonardi M, Franceschetti S, Panzica F. Altered resting state effective connectivity in long-standing vegetative state patients: an EEG study. Clin Neurophysiol 2013; 125:63-8. [PMID: 23927942 DOI: 10.1016/j.clinph.2013.06.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [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: 03/21/2013] [Revised: 05/21/2013] [Accepted: 06/11/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Recent evidence mainly based on hemodynamic measures suggests that the impairment of functional connections between different brain areas may help to clarify the neuronal dysfunction occurring in patients with disorders of consciousness (DOC). The aim of this study was to evaluate effective EEG connectivity in a cohort of 18 patients in a chronic vegetative state (VS) observed years after the occurrence of hypoxic (eight) and traumatic or hemorrhagic brain insult. METHODS we analysed the EEG signals recorded under resting conditions using a frequency domain linear index of connectivity (partial directed coherence: PDC) estimated from a multivariate autoregressive model. The results were compared with those obtained in ten healthy controls. RESULTS Our findings indicated significant connectivity changes in EEG activities in delta and alpha bands. The VS patients showed a significant and widespread decrease in delta band connectivity, whereas the alpha activity was hyper-connected in the central and posterior cortical regions. CONCLUSION These changes suggest the occurrence of severe circuitry derangements probably due to the loose control of the subcortical connections. The alpha hyper-synchronisation may be due to simplified networks mainly involving the short-range connections between intrinsically oscillatory cortical neurons that generate aberrant EEG alpha sources. This increased connectivity may be interpreted as a reduction in information capacity, implying an increasing prevalence of stereotypic activity patterns. SIGNIFICANCE Our observations suggest a remarkable rearrangement of connectivity in patients with long-standing VS. We hypothesize that in persistent VS, after a first period characterized by a breakdown of cortical connectivity, neurodegenerative processes, largely independent from the type of initial insult, lead to cortex de-afferentation and to a severe reduction of possible cortical activity patterns and states.
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Affiliation(s)
- Giulia Varotto
- Dept. of Neurophysiology and Diagnostic Epileptology, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Patrik Fazio
- Dept. of Neurophysiology and Diagnostic Epileptology, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy; Dept. of Medical and Surgical Sciences of Communication and Behaviour, Neurology Section, University of Ferrara, Italy
| | - Davide Rossi Sebastiano
- Dept. of Neurophysiology and Diagnostic Epileptology, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Dunja Duran
- Dept. of Neurophysiology and Diagnostic Epileptology, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Ludovico D'Incerti
- Dept. of Neuroradiology, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Eugenio Parati
- Dept. of Cerebrovascular Diseases, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Davide Sattin
- Unit of Neurology, Public Health, Disability Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy; Coma Research Centre, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Matilde Leonardi
- Unit of Neurology, Public Health, Disability Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy; Coma Research Centre, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Silvana Franceschetti
- Dept. of Neurophysiology and Diagnostic Epileptology, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Ferruccio Panzica
- Dept. of Neurophysiology and Diagnostic Epileptology, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy.
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23
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Alkadri ME, Peters MN, Katz MJ, White CJ. State-of-the-art paper: Therapeutic hypothermia in out of hospital cardiac arrest survivors. Catheter Cardiovasc Interv 2013; 82:E482-90. [PMID: 23475635 DOI: 10.1002/ccd.24914] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 01/12/2013] [Accepted: 03/03/2013] [Indexed: 11/09/2022]
Abstract
Out of hospital cardiac arrest (OHCA) is associated with an extremely poor survival rate, with mortality in most cases being related to neurological injury. Among patients who experience return of spontaneous circulation (ROSC), therapeutic hypothermia (TH) is the only proven intervention shown to reduce mortality and improve neurological outcome. First described in 1958, the field of TH has rapidly evolved in recent years. While recent technological advances in TH will likely improve outcomes in OHCA survivors, several fundamental questions remain to be answered including the optimal speed of cooling, which patients benefit from an early invasive strategy, and whether technological advances will facilitate application of TH in the field. An increased awareness and understanding of TH strategies, devices, monitoring, techniques, and complications will allow for a more widespread adoption of this important treatment modality.
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Affiliation(s)
- Mohi E Alkadri
- Department of Cardiology, Ochsner Medical Center, New Orleans, Louisiana
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