Fine tuning of neurointensive care in aneurysmal subarachnoid hemorrhage: From one-size-fits-all towards individualized care

Wettervik, Teodor Svedung; Lewén, Anders; Enblad, Per

doi:10.1016/j.wnsx.2023.100160

Cited by 7 publications

(6 citation statements)

References 154 publications

(217 reference statements)

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“…When the body is under stress, stress-induced hyperglycemia may occur [ 15 ]. Existing evidence suggests that in patients with moderate to severe traumatic brain injury, those who did not survive had higher blood lactate levels upon admission, indicating a correlation between elevated lactate levels, high blood glucose levels, abnormal coagulation function, and the severity of brain injury [ 16 ]. However, further research is needed to investigate the relationship between elevated blood lactate levels and stress-induced hyperglycemia in children with traumatic brain injury.…”

Section: Discussionmentioning

confidence: 99%

The significance of admission blood lactate and fibrinogen in pediatric traumatic brain injury: a single-center clinical study

Zhang,

Li,

Yan

et al. 2023

Childs Nerv Syst

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Background Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in pediatric patients, leading to long-term physical, cognitive, and psychological impairments. Blood lactate and fibrinogen levels have emerged as potential biomarkers associated with tissue hypoperfusion and coagulation dysfunction, respectively. However, limited research has specifically focused on the significance of these biomarkers in pediatric TBI. This study aimed to investigate the clinical significance of blood lactate and fibrinogen levels upon admission in pediatric patients with traumatic brain injury. Methods The medical records of 80 children with a traumatic brain injury who were admitted from January 2017 to January 2021 were retrospectively analyzed. The two groups were compared according to whether the blood lactate in the admission arterial blood gas increased and the fibrinogen content in the coagulation function decreased. The clinical data of the children in the two groups were different, and then they were divided into a good prognosis group and a poor prognosis group according to the GOS prognostic score, and the differences in the clinical indicators of the two groups were compared. Results Among the 80 patients, 33 had elevated blood lactate levels, 34 had decreased fibrinogen levels, and 29 had an unfavorable outcome (GOS < 4). Compared to the normal blood lactate group, there were no statistically significant differences in age, sex ratio, or platelet count in the elevated blood lactate group (P > 0.05). However, the elevated blood lactate group had lower Glasgow Coma Scale (GCS) scores upon admission, higher blood lactate levels, lower fibrinogen levels, longer hospital stay, lower GOS scores, and a higher proportion of GOS < 4 (P < 0.05). Compared to the normal fibrinogen group, there were no statistically significant differences in age, sex ratio, or platelet count in the decreased fibrinogen group (P > 0.05). However, the decreased fibrinogen group had lower GCS scores upon admission, higher blood lactate levels, lower fibrinogen levels, longer hospital stays, lower GOS scores, and a higher proportion of GOS < 4 (P < 0.05). Compared to the favorable outcome group, there were no statistically significant differences in age, sex ratio, or platelet count in the unfavorable outcome group (P > 0.05). However, the unfavorable outcome group had lower GCS scores upon admission, higher blood lactate levels, lower fibrinogen levels, longer hospital stays, a higher incidence of pulmonary infection, a higher incidence of stress ulcers, and lower GOS scores (P < 0.05). Conclusion The levels of blood lactate and fibrinogen may represent the severity of children with traumatic brain injury and may be risk factors for poor prognosis of children with traumatic brain injury.

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Section: Discussionmentioning

confidence: 99%

The significance of admission blood lactate and fibrinogen in pediatric traumatic brain injury: a single-center clinical study

Zhang,

Li,

Yan

et al. 2023

Childs Nerv Syst

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“…T he aim of neurointensive care is to monitor and manage systemic and cerebral physiology after severe acute brain injuries such as traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (aSAH). [1][2][3][4][5][6][7] The traditional management targets during neurointensive care include lowering elevated intracranial pressure (ICP) and managing blood pressure to maintain cerebral perfusion pressure (CPP) at levels sufficient to avoid cerebral ischemia; both these interventions apply to TBI and aSAH. 2,3,7 However, this approach has limitations because cerebral ischemia often occurs after TBI and aSAH despite "normal" ICP and CPP.…”

mentioning

confidence: 99%

“…[1][2][3][4][5][6][7] The traditional management targets during neurointensive care include lowering elevated intracranial pressure (ICP) and managing blood pressure to maintain cerebral perfusion pressure (CPP) at levels sufficient to avoid cerebral ischemia; both these interventions apply to TBI and aSAH. 2,3,7 However, this approach has limitations because cerebral ischemia often occurs after TBI and aSAH despite "normal" ICP and CPP. 8,9 In addition to vasospasm after aSAH, the homeostatic cerebral pressure autoregulatory function which maintains cerebral blood flow (CBF) unchanged over a wide range of CPP is often disrupted, making TBI and SAH patients susceptible to the development of both cerebral ischemia and hyperemia.…”

mentioning

confidence: 99%

“…8,9 In addition to vasospasm after aSAH, the homeostatic cerebral pressure autoregulatory function which maintains cerebral blood flow (CBF) unchanged over a wide range of CPP is often disrupted, making TBI and SAH patients susceptible to the development of both cerebral ischemia and hyperemia. 4,7,10,11 Consequently, there has been interest in monitoring cerebral autoregulatoy status as an adjunct to identify CPP targets during the neurointensive care management of TBI and aSAH. [11][12][13][14][15][16] Specifically, the pressure reactivity index (PRx) has become acknowledged as a feasible and valid method for the continuous monitoring of cerebral autoregulation.…”

mentioning

confidence: 99%

“…However, this approach has limitations because cerebral ischemia often occurs after TBI and aSAH despite “normal” ICP and CPP 8,9 . In addition to vasospasm after aSAH, the homeostatic cerebral pressure autoregulatory function which maintains cerebral blood flow (CBF) unchanged over a wide range of CPP is often disrupted, making TBI and SAH patients susceptible to the development of both cerebral ischemia and hyperemia 4,7,10,11 . Consequently, there has been interest in monitoring cerebral autoregulatoy status as an adjunct to identify CPP targets during the neurointensive care management of TBI and aSAH 11–16 .…”

mentioning

confidence: 99%

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Autoregulatory Cerebral Perfusion Pressure Insults in Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage: The Role of Insult Intensity and Duration on Clinical Outcome

Wettervik

Hånell

Howells

et al. 2023

Journal of Neurosurgical Anesthesiology

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Background: This single-center, retrospective study investigated the outcome effect of the combined intensity and duration of differences between actual cerebral perfusion pressure (CPP) and optimal cerebral perfusion pressure (CPPopt), and also for absolute CPP, in patients with traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (aSAH).Methods: A total of 378 TBI and 432 aSAH patients treated in a neurointensive care unit between 2008 and 2018 with at least 24 hours of CPPopt data during the first 10 days following injury, and with 6-month (TBI) or 12-month (aSAH) extended Glasgow Outcome Scale (GOS-E) scores, were included in the study. ΔCPPopt-insults (ΔCPPopt = actual CPP−CPPopt) and CPPinsults were visualized as 2-dimensional plots to highlight the combined effect of insult intensity (mm Hg) and duration (min) on patient outcome. Results:In TBI patients, a zone of ΔCPPopt ± 10 mm Hg was associated with more favorable outcome, with transitions towards unfavorable outcome above and below this zone. CPP in the range of 60 to 80 mm Hg was associated with higher GOS-E, whereas CPP outside this range was associated with lower GOS-E. In aSAH patients, there was no clear transition from higher to lower GOS-E for ΔCPPopt-insults; however, there was a transition from favorable to unfavorable outcome when CPP was <80 mm Hg.Conclusions: TBI patients with CPP close to CPPopt exhibited better clinical outcomes, and absolute CPP within the 60 to 80 mm Hg range was also associated with favorable outcome. In aSAH patients, there was no clear transition for ΔCPPopt-insults in relation to outcome, whereas generally high absolute CPP values were associated overall with favorable recovery.

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Thiopental and decompressive craniectomy as last-tier ICP-treatments in aneurysmal subarachnoid hemorrhage: is functional recovery within reach?

Björk,

Hånell,

Ronne-Engström

et al. 2023

Neurosurg Rev

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The study aimed to investigate the indication and functional outcome after barbiturates and decompressive craniectomy (DC) as last-tier treatments for elevated intracranial pressure (ICP) in aneurysmal subarachnoid hemorrhage (aSAH). This observational study included 891 aSAH patients treated at a single center between 2008 and 2018. Data on demography, admission status, radiology, ICP, clinical course, and outcome 1-year post-ictus were collected. Patients treated with thiopental (barbiturate) and DC were the main target group.Thirty-nine patients (4%) were treated with thiopental alone and 52 (6%) with DC. These patients were younger and had a worse neurological status than those who did not require these treatments. Before thiopental, the median midline shift was 0 mm, whereas basal cisterns were compressed/obliterated in 66%. The median percentage of monitoring time with ICP > 20 mmHg immediately before treatment was 38%, which did not improve after 6 h of infusion. Before DC, the median midline shift was 10 mm, and the median percentage of monitoring time with ICP > 20 mmHg before DC was 56%, which both significantly improved postoperatively. At follow-up, 52% of the patients not given thiopental or operated with DC reached favorable outcome, whereas this occurred in 10% of the thiopental and DC patients.In summary, 10% of the aSAH cohort required thiopental, DC, or both. Thiopental and DC are important integrated last-tier treatment options, but careful patient selection is needed due to the risk of saving many patients into a state of suffering.

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Fine tuning of neurointensive care in aneurysmal subarachnoid hemorrhage: From one-size-fits-all towards individualized care

Cited by 7 publications

References 154 publications

The significance of admission blood lactate and fibrinogen in pediatric traumatic brain injury: a single-center clinical study

The significance of admission blood lactate and fibrinogen in pediatric traumatic brain injury: a single-center clinical study

Autoregulatory Cerebral Perfusion Pressure Insults in Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage: The Role of Insult Intensity and Duration on Clinical Outcome

Thiopental and decompressive craniectomy as last-tier ICP-treatments in aneurysmal subarachnoid hemorrhage: is functional recovery within reach?

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