Background Therapeutic hypothermia is commonly used in comatose survivors’ post-cardiopulmonary resuscitation (CPR). It is unknown whether outcome predictors perform accurately after hypothermia treatment. Methods Post-CPR comatose survivors were prospectively enrolled. Six outcome predictors [pupillary and corneal reflexes, motor response to pain, and somatosensory-evoked potentials (SSEP) >72 h; status myoclonus, and serum neuron-specific enolase (NSE) levels <72 h] were systematically recorded. Poor outcome was defined as death or vegetative state at 3 months. Patients were considered “sedated” if they received any sedative drugs ≤12 h prior the 72 h neurological assessment. Results Of 85 prospectively enrolled patients, 53 (62%) underwent hypothermia. Furthermore, 53 of the 85 patients (62%) had a poor outcome. Baseline characteristics did not differ between the hypothermia and normothermia groups. Sedative drugs at 72 h were used in 62 (73%) patients overall, and more frequently in hypothermia than in normothermia patients: 83 versus 60% (P = 0.02). Status myoclonus <72 h, absent cortical responses by SSEPs >72 h, and absent pupillary reflexes >72 h predicted poor outcome with a 100% specificity both in hypothermia and normothermia patients. In contrast, absent corneal reflexes >72 h, motor response extensor or absent >72 h, and peak NSE >33 ng/ml <72 h predicted poor outcome with 100% specificity only in non-sedated patients, irrespective of prior treatment with hypothermia. Conclusions Sedative medications are commonly used in proximity of the 72-h neurological examination in comatose CPR survivors and are an important prognostication confounder. Patients treated with hypothermia are more likely to receive sedation than those who are not treated with hypothermia.
Background: Previous studies have shown that inpatient strokes are common and severe. We sought to characterize the risk factors, stroke subtypes, timing of acute stroke evaluation and frequency of thrombolytic therapy in inpatient ischemic strokes compared with community ischemic strokes. Design/Methods: The hospital records of patients admitted for acute ischemic stroke between 1996 and 2002 were reviewed. Acute stroke was defined as occurrence of stroke symptoms within 72 h, and in-hospital status was assigned if the patient was currently admitted for another illness at the time of the stroke. Patient demographics such as medical versus surgical service, admission diagnoses, clinical features including stroke risk factors, access to thrombolytic therapy and immediate outcome were analyzed. Results: Of 947 patients with acute ischemic stroke, 161 (17.0%) had strokes occurring while already in the hospital (IHIS), compared to 786 (83%) that occurred in the outpatient community (CIS). Approximately two thirds of IHIS occurred on medical services (102, 63.4%) and one third on surgical services (59, 36.7%). Mean age, male gender, atherothrombotic etiology and risk factors including hypertension, diabetes and smoking history were of similar frequencies in IHIS and CIS, but penetrating artery disease was the cause of only 5.6% of IHIS compared to 21.8% of CIS (p < 0.0001). The mean modified Rankin scale for IHIS at presentation was 4.33 ± 0.74, compared to 3.67 ± 1.03 for CIS (p < 0.0001). Of 161 IHIS patients, 21 (13.0%) had neurological assessment within 3 h of symptom onset, compared to 16.0% of CIS patients (p = 0.403, n.s.), and the rate of thrombolytic therapy was not significant between IHIS (3.7%) and CIS (5.6%) patients. Conclusions: IHIS are common and severer than CIS. The use of thrombolytic therapy in IHIS patients was limited because of time of recognition and inpatient-associated conditions. Increased vigilance for timely neurological assessment of these patients is warranted.
OBJECTIVE The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%-7% per year despite receiving the best available medical therapy. Here, authors propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA and to assess the changes in systemic blood pressure following successful revascularization. METHODS The radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients, five of whom were female (5/31 [16.13%]). Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Carotid artery occlusion was defined as 100% cross-sectional occlusion of the vessel lumen as documented on CTA or MRA and confirmed by digital subtraction angiography. RESULTS Four types (A-D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75% (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75% (6/32; type A: 0/8 [0%]; type B: 1/8 [12.50%]; type C: 3/8 [37.50%], type D: 2/8 [25.00%]). None of these complications led to permanent morbidity or death. Twenty (64.52%) of 31 subjects had improvement in their symptoms at the 2-6 months' follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95%) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73). CONCLUSIONS The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.
Neurocritical care patients are at risk of developing secondary brain injury from inflammation, ischemia, and edema that follows the primary insult. Recognizing clinical deterioration due to secondary injury is frequently challenging in comatose patients. Multimodality monitoring (MMM) encompasses various tools to monitor cerebral metabolism, perfusion, and oxygenation aimed at detecting these changes to help modify therapies before irreversible injury sets in. These tools include intracranial pressure (ICP) monitors, transcranial Doppler (TCD), Hemedex™ (thermal diffusion probe used to measure regional cerebral blood flow), microdialysis catheter (used to measure cerebral metabolism), Licox™ (probe used to measure regional brain tissue oxygen tension), and continuous electroencephalography. Although further research is needed to demonstrate their impact on improving clinical outcomes, their contribution to illuminate the black box of the brain in comatose patients is indisputable. In this review, we further elaborate on commonly used MMM parameters, tools used to measure them, and the indications for monitoring per current consensus guidelines.
High-resolution vessel wall imaging (HR-vwi) is becoming a useful tool in the characterization and identification of unstable unruptured brain aneurysms. However, it has not been validated for clinical use. The current evidence on HR-vwi techniques for characterization of brain aneurysms is described in this review. Specific imaging approaches such as aneurysm wall contrast enhancement, MRi-quantitative susceptibility mapping, and 7T MRi are described in detail.
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