Favorable Neurological Outcome Research Articles

Outcomes of patients with intermediate-risk neuroblastoma presenting with motor deficits relating to intraspinal tumor extension: A report from the Children's Oncology Group study ANBL0531.

Tumor invasion of the spinal canal is detected radiographically in approximately 15% of patients with newly diagnosed neuroblastoma (NB). The optimal clinical approach to maintain excellent survival outcomes while minimizing long-term sequelae is yet to be defined. Patients with intermediate-risk neuroblastoma (IR-NB) and radiographically identified intraspinal tumors who were treated on the Children's Oncology Group study ANBL0531 were studied prospectively to evaluate neurologic outcomes related to cord compression. Patients were defined as being symptomatic versus asymptomatic based on reporting of neurologic motor deficits at diagnosis. Patient characteristics, tumor biology, chemotherapy treatment, surgical interventions, and neurologic and disease outcomes are reported. Of the 92 patients with intraspinal tumors, 42 (46%) were symptomatic and most (73%) had complete resolution of symptoms. Age, degree of motor deficit, and duration of symptoms at diagnosis were not associated with complete resolution. While symptomatic patients were more likely to undergo upfront laminectomy, laminectomy was not associated with improvement of motor symptoms. Administration of additional chemotherapy beyond initial treatment assigned per protocol to achieve the treatment end point was not associated with achieving symptom resolution. Patients presenting with motor deficits due to intraspinal tumor had excellent survival and favorable neurologic outcomes, with the majority reporting complete resolution of motor symptoms regardless of severity and duration of symptoms at diagnosis or neurosurgical intervention. Prompt diagnosis and initiation of first-line chemotherapy treatment remain priority, while neurosurgical intervention should be reserved for patients with rapid neurologic deterioration. Biology-based therapy and tumor response should continue to be used to maintain favorable outcomes.

Intraosseous and Intravenous Epinephrine Administration Routes in Out-of-Hospital Cardiac Arrest: Survival and Neurologic Outcomes.

The rate of survival after out-of-hospital cardiac arrest varies depending on the timeliness and effectiveness of prehospital interventions. This study was conducted to compare out-of-hospital cardiac arrest outcomes between intravenous and intraosseous routes and between upper and lower extremity routes for drug administration. We retrospectively analyzed data (collected using the Utstein template) from 1220 patients who had experienced out-of-hospital cardiac arrest in Taiwan's Taoyuan City between January 2021 and August 2023. The patients were stratified into intravenous and intraosseous groups by treatment approach and upper and lower extremity access groups by access site. The study outcomes were survival to discharge, favorable neurologic outcomes (Cerebral Performance Category score 1 or 2), and survival for >2 hours. The study groups were statistically compared before and after propensity score matching. Significant pre-propensity score matching differences were observed between intravenous and intraosseous groups, and the aforementioned study outcomes were better in the intravenous group than in the intraosseous group. However, the between-group differences became nonsignificant after propensity score matching. Furthermore, lower extremity access and delayed epinephrine administration were associated with worse outcomes. Survival rates fell below 12.6% when time to treatment exceeded 15 minutes, particularly in the cases of intraosseous access and lower extremity access. This study highlights the benefits of early intervention and upper extremity access for drug administration in patients with out-of-hospital cardiac arrest. Intraosseous access may serve as a viable alternative to intravenous access. Timely administration of essential drugs during resuscitation can improve clinical outcomes and thus has implications for emergency medical service training.

Prehospital endotracheal intubation for traumatic out-of-hospital cardiac arrest and improved neurological outcomes.

Patients with traumatic out-of-hospital cardiac arrest (t-OHCA) require on-scene airway management to maintain tissue oxygenation. However, the benefits of prehospital endotracheal intubation remain unclear, particularly regarding neurological outcomes. Therefore, this study aimed to evaluate the association between prehospital intubation and favourable neurological outcomes in patients with t-OHCA. This retrospective cohort study used a Japanese nationwide trauma registry from 2019 to 2021. It included adult patients diagnosed with traumatic cardiac arrest on emergency medical service arrival. Glasgow Outcome Scale (GOS) scores, survival at discharge and presence of signs of life on hospital arrival were compared between patients with prehospital intubation and those with supraglottic airway or manual airway management. Inverse probability weighting with propensity scores was used to adjust for patient, injury, treatment and institutional characteristics, and the effects of intubation on outcomes averaged over baseline covariates were shown as marginal ORs. A total of 1524 patients were included in this study, with 370 undergoing intubation before hospital arrival. Prehospital intubation was associated with favourable neurological outcomes at discharge (GOS≥4 in 5/362 (1.4%) vs 10/1129 (0.9%); marginal OR 1.99; 95% CI 1.12 to 3.53; p=0.021) and higher survival to discharge (25/370 (6.8%) vs 63/1154 (5.5%); marginal OR 1.43; 95% CI 1.08 to 1.90; p=0.012). However, no association with signs of life on hospital arrival was observed (65/341 (19.1%) vs 147/1026 (14.3%); marginal OR 1.09; 95% CI 0.89 to 1.34). Favourable outcomes were observed only in patients who underwent intubation with a severe chest injury (Abbreviated Injury Score ≥3) and with transportation time to hospital >15 min (OR 14.44 and 2.00; 95% CI 1.89 to 110.02 and 1.09 to 3.65, respectively). Prehospital intubation was associated with favourable neurological outcomes among adult patients with t-OHCA who had severe chest injury or transportation time >15 min.

Signs of life as a favorable predictor for non-shockable cardiac arrest undergoing extracorporeal cardiopulmonary resuscitation post non-shockable cardiac arrest

BackgroundWhen the initial rhythm of cardiac arrest is non-shockable, resuscitation outcomes tend to be unfavorable. However, signs of life (gasping, pupillary light reaction, or any form of body movement) have been suggested as favorable prognostic factors for patients with refractory cardiac arrest who are undergoing extracorporeal cardiopulmonary resuscitation (ECPR). This study determined whether signs of life are favorable neurological prognostic factors for patients undergoing ECPR post non-shockable cardiac arrest. Methods and resultsThis single-center retrospective study included 227 refractory out-of-hospital cardiac-arrest patients who had undergone ECPR, divided into four groups according to shockability of initial cardiac rhythms and presence of signs of life. Initial cardiac rhythms were shockable in 154 patients (67.8 %) and non-shockable in 73 (32.2). Favorable neurological outcomes were observed in 4.1 %, 48.2 %, 0.0 %, and 38.7 % of patients with shockable rhythm without signs of life, shockable rhythm with signs of life, non-shockable rhythm without signs of life, and non-shockable rhythm with signs of life, respectively, with significant differences. Multivariate logistic regression analysis showed an independent association of signs of life during resuscitation with favorable neurological outcomes. The adjusted odds ratios for patients with shockable and non-shockable rhythm with signs of life were 34.33 and 96.51, respectively, compared with those without signs of life. ConclusionsSigns of life during resuscitation were favorable prognostic factors in patients with refractory cardiac arrest and non-shockable rhythm. When these patients are considered for ECPR, the status of signs of life during resuscitation may facilitate the decision to perform ECPR.

The impact of door to extracorporeal cardiopulmonary resuscitation time on mortality and neurological outcomes among out-of-hospital cardiac arrest acute myocardial infarction patients treated by primary percutaneous coronary intervention

BackgroundFew previous studies evaluated the impact of time from the hospital arrival to the implementation of extracorporeal cardiopulmonary resuscitation (ECPR) (door to ECPR time) on outcomes among out-of-hospital cardiac arrest (OHCA) acute myocardial infarction (MI) patients. Methods50 patients with OHCA who received both ECPR and percutaneous coronary intervention (PCI) at Cardiovascular Division, NHO Osaka National Hospital were analyzed. Patients were divided into 2 groups according to the median of door to ECPR time. The primary outcome was all-cause death. Survival analyses were conducted to compare all-cause mortality at 90 days between 2 groups. Neurological outcome at 30 days was also compared between 2 groups using the Cerebral Performance Category (CPC). ResultsThe multivariable Cox proportional-hazards model showed that all-cause mortality at 90 days was significantly higher among patients with door to ECPR time ≥ 25 min compared with those with door to ECPR time < 25 min (adjusted hazard ratio [HR]: 3.14; 95 % confidence interval [CI]: 1.21–8.18). The proportion of patients with CPC at 30 days ≤ 2 was significantly higher among patients with shorter door to ECPR time (P = 0.048). ConclusionAmong patients with OHCA due to acute MI who received ECPR and PCI, the shorter door to ECPR time was associated with the lower mortality and favorable neurological outcomes.

Outcomes of extracorporeal life support in hypothermic cardiac arrest: Revisiting ELSO guidelines

Aim of the studyPredictive factors for poor outcomes in hypothermic cardiac arrest (HCA) differ from those in normothermic out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the outcomes of extracorporeal life support (ECLS) in HCA patients who may not be considered eligible based on the guidelines set by the Extracorporeal Life Support Organization (ELSO). MethodsA retrospective multicentre study included 127 HCA patients, divided into two groups: those meeting the ELSO eligibility criteria for ECLS, and those with at least one of the following ELSO exclusion criteria: age over 70 years, unwitnessed cardiac arrest, or asystole. ResultsAmong the 62 patients who met the ELSO criteria, 38 (61 %) survived to hospital discharge, with 34 (89 %) achieving a favourable neurological outcomes. Of the 65 patients who received ECLS despite not meeting ELSO criteria, 24 (37 %) survived to discharge, with 20 (83 %) demonstrating a favourable neurological outcomes. In patients not meeting one or two ELSO criteria, survival rates were 18 of 47 (38 %) and 6 of 16 (38 %) respectively, with 83 % of survivors in both groups achieving favourable neurological outcomes. The two patients who failed to meet all three ELSO criteria did not survive. ConclusionQualification of patients with hypothermic cardiac arrest for ECLS rewarming should not be strictly based on guidelines for normothermic cardiac arrest, as this may result in not initiating potentially life-saving treatment for patients who could have favourable prognoses for survival with good neurological outcomes.

The frontal aslant tract: Anatomical description and case report

Background: Advances in surgical techniques, neuroimaging, and white matter fiber dissection have facilitated the identification of critical tracts like the frontal aslant tract (FAT) that have garnered attention, despite remaining poorly recognized within the neurosurgical community. Case Description: We report the case of a 37-year-old male right-handed patient presenting with headache and epilepsy, in whom neuroimaging revealed an intra-axial lesion in the left middle frontal gyrus closely associated with FAT. Successful navigation-guided resection of the lesion was achieved, resulting in a favorable neurological outcome attributable to the preservation of the tract. This case is complemented by a review of the literature and anatomical dissection of FAT in a human specimen. Conclusion: The FAT has emerged as a critical white matter structure in neurosurgery, given its involvement in speech and motor functions. This case demonstrates the importance of advanced imaging modalities and intraoperative technologies to ensure safe resection.

Sex differences in extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: nationwide multicenter retrospective study in Japan

BackgroundPrevious studies examining sex differences in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) have indicated that women have favorable outcomes; however, detailed evidence remains lacking. We aimed to investigate sex differences in the backgrounds and outcomes of patients undergoing ECPR for OHCA.MethodsThis study was a secondary analysis of the registry from the SAVE-J II study, a retrospective multicenter study conducted in Japan from 2013 to 2018. Adult patients without external causes who underwent ECPR for OHCA were included. The primary outcome was a favorable neurological outcome (Cerebral Performance Status 1 or 2) at hospital discharge. We used multilevel logistic regression to evaluate the association of sex differences, adjusting for center-level (hospital) and individual-level variables (patient background, cardiac arrest situation, and in-hospital intervention factors). For sensitivity analyses, we performed three models of multilevel logistic regression when selecting confounders.ResultsAmong the 1819 patients, 1523 (83.7%) were men, and 296 (16.3%) were women. The median age (61.0 vs. 58.0 years), presence of a witness (78.8% vs. 79.2%), and occurrence of bystander CPR (57.5% vs. 61.6%) were similar between groups. Women were more likely to present with an initial non-shockable rhythm (31.7% vs. 49.7%), as well as a non-shockable rhythm at hospital arrival (52.1% vs. 61.5%) and at ECMO initiation (48.1% vs. 57.1%). The proportion of favorable neurological outcomes was 12.3% in males and 15.9% in females (p = 0.10). Multilevel logistic regression analysis showed that the female sex was significantly associated with a favorable neurologic outcome at discharge (adjusted odds ratio: 1.60 [95% confidence interval: 1.05–2.43]; p = 0.03). This advantage in women was consistently observed in the sensitivity analyses.ConclusionsThe female sex is significantly associated with favorable neurological outcomes at hospital discharge in patients who received ECPR for OHCA.

Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest.

Out-of-hospital cardiac arrest is a leading cause of death worldwide. Establishing vascular access is critical for administering guideline-recommended drugs during cardiopulmonary resuscitation. Both the intraosseous route and the intravenous route are used routinely, but their comparative effectiveness remains unclear. We conducted a randomized clinical trial to compare the effectiveness of initial attempts at intraosseous or intravenous vascular access in adults who had nontraumatic out-of-hospital cardiac arrest. The primary outcome was a sustained return of spontaneous circulation. Key secondary outcomes were survival at 30 days and survival at 30 days with a favorable neurologic outcome, defined by a score of 0 to 3 on the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability). Among 1506 patients who underwent randomization, 1479 were included in the primary analysis (731 in the intraosseous-access group and 748 in the intravenous-access group). The successful establishment of vascular access within two attempts occurred in 669 patients (92%) assigned to the intraosseous-access group and in 595 patients (80%) assigned to the intravenous-access group. Sustained return of spontaneous circulation occurred in 221 patients (30%) in the intraosseous-access group and in 214 patients (29%) in the intravenous-access group (risk ratio, 1.06; 95% confidence interval [CI], 0.90 to 1.24; P = 0.49). At 30 days, 85 patients (12%) in the intraosseous-access group and 75 patients (10%) in the intravenous-access group were alive (risk ratio, 1.16; 95% CI, 0.87 to 1.56); a favorable neurologic outcome at 30 days occurred in 67 patients (9%) and 59 patients (8%), respectively (risk ratio, 1.16; 95% CI, 0.83 to 1.62). Prespecified adverse events were uncommon. There was no significant difference in sustained return of spontaneous circulation between initial intraosseous and intravenous vascular access in adults who had out-of-hospital cardiac arrest. (Funded by the Novo Nordisk Foundation and others; IVIO EU Clinical Trials Register number, 2022-500744-38-00; ClinicalTrials.gov number, NCT05205031.).

A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest.

In patients with out-of-hospital cardiac arrest, the effectiveness of drugs such as epinephrine is highly time-dependent. An intraosseous route of drug administration may enable more rapid drug administration than an intravenous route; however, its effect on clinical outcomes is uncertain. We conducted a multicenter, open-label, randomized trial across 11 emergency medical systems in the United Kingdom that involved adults in cardiac arrest for whom vascular access for drug administration was needed. Patients were randomly assigned to receive treatment from paramedics by means of an intraosseous-first or intravenous-first vascular access strategy. The primary outcome was survival at 30 days. Key secondary outcomes included any return of spontaneous circulation and favorable neurologic function at hospital discharge (defined by a score of 3 or less on the modified Rankin scale, on which scores range from 0 to 6, with higher scores indicating greater disability). No adjustment for multiplicity was made. A total of 6082 patients were assigned to a trial group: 3040 to the intraosseous group and 3042 to the intravenous group. At 30 days, 137 of 3030 patients (4.5%) in the intraosseous group and 155 of 3034 (5.1%) in the intravenous group were alive (adjusted odds ratio, 0.94; 95% confidence interval [CI], 0.68 to 1.32; P = 0.74). At the time of hospital discharge, a favorable neurologic outcome was observed in 80 of 2994 patients (2.7%) in the intraosseous group and in 85 of 2986 (2.8%) in the intravenous group (adjusted odds ratio, 0.91; 95% CI, 0.57 to 1.47); a return of spontaneous circulation at any time occurred in 1092 of 3031 patients (36.0%) and in 1186 of 3035 patients (39.1%), respectively (adjusted odds ratio, 0.86; 95% CI, 0.76 to 0.97). During the trial, one adverse event, which occurred in the intraosseous group, was reported. Among adults with out-of-hospital cardiac arrest requiring drug therapy, the use of an intraosseous-first vascular access strategy did not result in higher 30-day survival than an intravenous-first strategy. (Funded by the National Institute for Health and Care Research; PARAMEDIC-3 ISRCTN Registry number, ISRCTN14223494.).

Validation of CASPRI, GO-FAR, PIHCA scores in predicting favorable neurological outcomes after in-hospital cardiac arrest; A five-year three center retrospective study in IRAN

BackgroundPredicting neurological outcomes following in-hospital cardiac arrest is crucial for guiding subsequent clinical treatments. This study seeks to validate the effectiveness of the CASPRI, GO-FAR, and PIHCA tools in predicting favorable neurological outcomes after in-hospital cardiac arrest.MethodThis retrospective study utilized a Utstein-style structured form to review the medical records of patients who experienced in-hospital cardiac arrest between March 2018 and March 2023. Predictors were examined using multivariable logistic regression, and the validity of the tools was assessed using ROC curves. Statistical analysis was conducted using SPSS version 25 software.ResultsOut of the 1100 patients included in the study, 42 individuals (3.8%) achieved a favorable neurological outcome. multivariable regression analysis revealed that age, respiratory failure, resuscitation shift, duration of renal failure, and CPC score 24 h before cardiac arrest were significantly associated with favorable neurological outcomes. The predictive abilities of the CASPRI, GO-FAR, and PIHCA scores were calculated as 0.99 (95% CI, 0.98–1.00), 0.98 (95% CI, 0.97–0.99), and 0.96 (95% CI, 0.94–0.99) respectively. A statistically significant difference was observed in the predictive abilities of the CASPRI and PIHCA scores (P = 0.001), while the difference between CASPRI and GO-FAR did not reach significance (P = 0.057). Additionally, there was no significant difference between the predictive abilities of GO-FAR and PIHCA scores (P = 0.159).ConclusionThe study concludes that CASPRI and GO-FAR scores show strong potential as objective measures for predicting favorable neurological outcomes post-cardiac arrest. Integrating these scores into clinical decision-making may enhance treatment and care strategies, in the Iranian healthcare context.

Complete vs culprit-lesion-only myocardial revascularization in patients with out-of-hospital cardiac arrest: insights from the multicentric "Lombardia CARe" registry

Abstract Background Out-of-hospital Cardiac Arrest (OHCA) is a potentially devastating complication of patients with Myocardial Infarction (MI). Multivessel Disease (MVD) is a frequent occurrence in this setting, being present in nearly half patients undergoing Coronary Angiography (CAG). We previously reported that, in case of MI complicated by OHCA and evidence of MVD, a complete myocardial revascularization, as compared to culprit-lesion-only revascularization, was associated with an improved 1-year survival and favorable neurological outcomes. We aimed to validate and confirm these results on a multicentric scale with a larger patient cohort. Methods This is a multicentric, prospective, observational study. We considered all the consecutive patients with OHCA and MI enrolled in the Lombardia CARe Registry from January 1st 2015 to December 31st 2022 who underwent CAG in 6 centers in Northen Italy. Results A total of 623 patients were included; of these, 403 underwent CAG. Median age was 64 years, and about 80% had no previous history of ischemic heart disease. Median ejection fraction (EF) at presentation was 40%. MVD was present in 186 (46.1%) patients and was subsequently treated with either complete (32.3%) or incomplete (67.7%) coronary revascularization. Left anterior descendent (LAD) artery was the culprit lesion in almost 1/3 of patients. The 1-year survival rate was 78.3% in the complete revascularization group and 42.9% in the culprit-lesion-only revascularization group (p-value &amp;lt; 0.001). After correction for factors that were predictors on univariate analysis, complete revascularization strategy was independently associated with a reduced risk of death [HR: 0.27 (95% CI: 0.01 to 0.739; p = 0.01] and death or unfavorable neurological outcome [HR: 0.23 (95% CI: 0.08 to 0.67); p = 0.007]. Conclusions Complete revascularization strategy was confirmed to be associated with an improvement of 1-year survival and with a good neurological outcome in patients resuscitated from OHCA. These results highlight the independent impact on survival of a complete coronary intervention strategy in patients with OHCA plus MVD.

Factors associated with neurological outcomes in patients experiencing out-of-hospital cardiac arrest and severe acidaemia: retrospective analysis of a nation-wide registry

Background and objectiveAcidaemia is common among individuals who experience out-of-hospital cardiac arrest (OHCA). While severe acidaemia is a strong predictor of unfavourable outcomes, a subset of patients exhibits dramatic recovery. Despite these conflicting outcomes, little is known about the factors associated with neurological outcomes in those who experience OHCA with severe acidaemia. MethodsThis retrospective analysis used data from a Japanese multicentre nationwide database, the Japanese Association for Acute Medicine OHCA Registry. The analysis included data from adult patients with OHCA for whom blood pH data were available upon arrival to hospital. The primary outcome was 30-day survival with favourable neurological outcomes, defined as a Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Patients were categorised with severe acidaemia if their blood pH was ≤ 6.8. Factors associated with favourable outcomes were investigated using multiple logistic regression analysis. ResultsData from 49,044 patients were included in the analysis, of whom 16,620 exhibited severe acidaemia with a median pH of 6.70 (interquartile range [IQR] 6.61–6.76], and 0.5% (86/16,620) experienced a neurologically favourable outcome. After adjustment for important prognostic factors, witnessed status exhibited a strong association with favourable neurological outcome (adjusted odds ratio [aOR] 6.46 [95% confidence interval (CI) 2.64–15.8]), while initial blood pH exhibited no significant association (aOR 0.90 with every 0.1 unit increase [95% CI 0.71–1.14]). ConclusionAlthough the number is small, a notable number of patients with severe acidaemia exhibited good neurological recovery. Witness status was critical for the prognosis of these patients.

The association between early hypotension and neurologic outcome after pediatric cardiac ECPR in children with cardiac disease

ObjectiveExplore the relationship between early hypotension after ECPR and survival to hospital discharge (SHD) with favorable neurologic outcome (FNO) in children with cardiac disease. MethodsRetrospective cohort study of patients undergoing ECPR at a single center pediatric cardiac intensive care unit. Hypotension was defined as MAP < 5th percentile for age. Primary and secondary exposure variables were presence and burden of hypotension respectively, during the first 6 h after ECPR. Our primary outcome was SHD with FNO defined by Pediatric Cerebral Performance Category score of 1–3 or no change from baseline. Secondary outcomes included acute central nervous system (CNS) injury via neuroimaging and EEG. Univariate and multivariable logistic regression analyses were performed. ResultsWe analyzed 82 index ECPR events from 2010 to 2022. Hypotension was observed for at least one MAP value in 36/82 (43.9%) of the cohort. The median [IQR] burden of hypotension was 0 [0,14.3]%. Patients with SHD with FNO had shorter CPR duration, lower number of epinephrine and calcium doses, and lower maximum lactate levels when compared to patients who died or had SHD without FNO. After controlling for potential confounders, there was no association between presence of hypotension or burden of hypotension and SHD, SHD with FNO, or acute CNS injury via neuroimaging and EEG. ConclusionIn children with cardiac disease, there was no association between early hypotension after ECPR and SHD with FNO. Multicenter studies are needed to better understand how early hypotension after ECPR affects neurologic outcomes in children with cardiac disease.

Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration in Out-of-Hospital Cardiac Arrest - Composite Time-Dependent Effects of Prehospital Interventions on 30-Day Favorable Neurological Outcomes and Social Implications From a Prospective Nationwide Population-Based Cohort Study.

Our study investigated the prognostic impacts of the interval between collapse and the initiation of cardiopulmonary resuscitation (CPR), and subsequent intervals to defibrillation or epinephrine administration, on 30-day favorable neurological outcomes following out-of-hospital cardiac arrest (OHCA). This nationwide population-based cohort study used the All Japan Utstein Registry, encompassing OHCA patients in Japan between January 2006 and December 2021. The primary outcome was 30-day favorable neurological outcomes, defined as Cerebral Performance Category 1 or 2. Three-dimensional plots and multivariable logistic regression models were used to assess the time-dependent prognostic impacts of prehospital CPR interventions. In all, 184,731 OHCA patients (86,246 with shockable rhythm and 98,485 with non-shockable rhythm) were included in the study. Three-dimensional plots revealed that the interval between collapse and initiation of CPR, and subsequent intervals to defibrillation or epinephrine, were independently associated with 30-day favorable neurological outcomes in the groups with shockable and non-shockable rhythms, respectively (P<0.05 for all). Among patients with witnessed OHCA, there was a dose-response relationship between delays in the collapse-CPR initiation interval, and subsequent intervals to defibrillation or epinephrine administration, and 30-day favorable neurological outcomes. Our findings provide valuable insights into OHCA management.

Neurosurgical Procedures in Patients Requiring Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is often withheld in patients with significant neurologic injury or recent neurosurgical intervention due to perceived futility. Studies of neurosurgical interventions before or during ECMO are limited to case reports or single-center series, limiting generalizability, and outcomes in this population are unknown. We therefore sought to report the outcomes of ECMO patients with acute neurosurgical interventions at four high-volume ECMO and comprehensive stroke centers. Retrospective case series. Four academic tertiary referral hospitals in the United States. Adults (n = 24) having undergone neurosurgical procedures before or during ECMO. None. We retrospectively reviewed adults at four institutions who had undergone neurosurgical procedures immediately before or during ECMO from 2015 to 2023. The primary outcome was survival to hospital discharge. Secondary outcomes included favorable neurologic outcome (Cerebral Performance Category 1 or 2) and neurosurgical complications. Twenty-four of 2957 ECMO patients (0.8%) were included. Primary indications for neurosurgical intervention included traumatic brain (n = 8) or spinal (n = 3) injury, spontaneous intracranial hemorrhage (n = 6), and acute ischemic stroke (n = 5). Procedures included extraventricular drain (EVD) and/or intracranial pressure monitor placement (n = 10), craniectomy/craniotomy (n = 5), endovascular thrombectomy (n = 4), and spinal surgery (n = 3). Fifteen patients (63%) survived to hospital discharge, of whom 12 (80%) were discharged with favorable neurologic outcomes. Survival to discharge was similar for venoarterial and venovenous ECMO patients (8/12 vs. 7/12; p = 0.67) and those who had neurosurgery before vs. during ECMO (8/13 vs. 7/11; p = 0.92). One patient (4%) experienced a neurosurgical complication, a nonlethal tract hemorrhage from EVD placement. Survival to discharge was similar for neurosurgical and nonneurosurgical ECMO patients at participating institutions (63% vs. 57%; p = 0.58). Patients with acute neurologic injury can feasibly undergo neurosurgery during ECMO or can undergo ECMO after recent neurosurgery. Larger studies are needed to fully understand risks for bleeding and other procedure-related complications.

Improved Door-to-Needle Time After Implementation of Tenecteplase as the Preferred Thrombolytic for Acute Ischemic Stroke at a Large Community Teaching Hospital Emergency Department

Background: Acute ischemic stroke is a leading cause of death and long-term disability. To improve patient outcomes, timely restoration of blood flow to the ischemic brain tissue is vital. One reperfusion strategy includes the administration of thrombolytics. Historically, alteplase has been the thrombolytic of choice for acute ischemic stroke; however, given recent safety and efficacy data, tenecteplase has gained popularity due to its optimal pharmacokinetic profile. Objectives: This study compares outcomes between adult patients with acute ischemic stroke who received tenecteplase as the preferred thrombolytic versus alteplase. Methods: This was a single center, retrospective cohort study that included adult patients who received intravenous thrombolytic therapy, either tenecteplase 0.25 mg/kg or alteplase 0.9 mg/kg, for acute ischemic stroke from May 2021 to December 2023. The primary outcome was door-to-needle time. Secondary safety outcomes included the incidence of symptomatic intracerebral hemorrhage (ICH), any ICH on 24-hour follow-up imaging, major extracranial bleeding, and angioedema. Secondary efficacy outcomes included discharge with a favorable neurological outcome, discharge disposition, ICU length of stay, and overall length of stay. Secondary stroke metric times evaluated include door-to-computed tomography (CT) time, CT-to-needle time, neurologist notification-to-needle time, and thrombolytic decision-to-needle time. Results: Fifty patients were included in the alteplase group and 50 patients were included in the tenecteplase group. The primary outcome, door-to-needle time, was significantly shorter in the tenecteplase group (36 vs 30 minutes, P = .006). There were no statistically significant differences found in the secondary safety and efficacy outcomes. Patients who received tenecteplase experienced significantly faster CT-to-needle times (17 vs 11 minutes, P = .006), neurologist notification-to-needle times (32 vs 25 minutes, P = .001), and thrombolytic decision-to-needle times (9 vs 5 minutes, P &lt; .001). Conclusions: In this retrospective, observational study, there was a statistically significant decrease in door-to-needle time with tenecteplase compared to alteplase. No significant differences in secondary safety and efficacy outcomes were observed.

Association of Prehospital Rearrest With Outcome Following Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis of Observational Studies

Objectives Exposure to prehospital rearrest has previously been associated with mortality following out-of-hospital cardiac arrest (OHCA). Our objective was to conduct a systematic review and meta-analysis examining the association between prehospital rearrest and survival in adults following OHCA resuscitation. Methods We searched the PubMed, Scopus, and Web of Science bibliographic databases for observational studies that included adult OHCA patients who achieved return of spontaneous circulation in the prehospital setting following OHCA and reported survival to hospital discharge data stratified by rearrest status. The primary exposure was prehospital rearrest. The primary outcome for this study was survival to hospital discharge. Secondary outcomes included survival with a favorable neurological outcome and rearrest prevalence. We pooled data using inverse heterogeneity modeling and presented effect sizes for the survival outcomes as odds ratios with 95% confidence intervals. We quantified heterogeneity using Cochran’s Q and the I2 statistic and examined small study effects using Doi plots and the LFK index. Results Of the 84 publications screened, we included 7 observational studies containing 27,045 patients with survival to hospital discharge data. Rearrest was common (30% [18–43%]; n = 7 studies; Q = 1086.1, p < 0.001; I2 = 99%; LFK index = 1.21) and associated with both decreased odds of survival to discharge (pooled aOR: 0.27 [0.22, 0.33]; n = 7 studies; Q = 32.2, p < 0.01, I2 = 81%, LFK index = −0.08) and decreased odds of survival to discharge with a favorable neurological outcome (pooled aOR: 0.25, [0.22, 0.28]; n = 4 studies; Q = 3.5, p = 0.3; I2 = 13%, LFK index = 1.30). Conclusions Rearrest is common and associated with decreased survival following OHCA. The pooled result of this meta-analysis suggests that preventing rearrest in five patients would be necessary to save one life.

Outcomes of adolescent children with severe cardiogenic shock referred for extracorporeal membrane oxygenation: insight from collaboration of adult shock team and paediatric cardiac critical care.

Adolescents with severe cardiogenic shock can present to both paediatric and adult centres. We present six adolescent children who had extracorporeal membrane oxygenation consultation fast-tracked with clinical care input from the adult multidisciplinary team, including interhospital transfers on extracorporeal membrane oxygenation. After recovery on conventional cardiogenic shock care or extracorporeal membrane oxygenation, or bridge to transplant, all had favourable neurologic outcome.

Brain tissue oxygen pressure combined with intracranial pressure monitoring may improve clinical outcomes for patients with severe traumatic brain injury: a systemic review and meta-analysis.

Although the optimization of brain oxygenation is thought to improve the prognosis, the effect of brain tissue oxygen pressure (PbtO2) for patients with severe traumatic brain injury (STBI) remains controversial. Therefore, the present study aimed to determine whether adding PbtO2 to intracranial pressure (ICP) monitoring improves clinical outcomes for patients with STBI. PubMed, Embase, Scopus and Cochrane Library were searched for eligible trials from their respective inception through April 10th, 2024. We included clinical trials contrasting the combined monitoring of PbtO2 and ICP versus isolated ICP monitoring among patients with STBI. The primary outcome was favorable neurological outcome at 6 months, and secondary outcomes including the in-hospital mortality, long-term mortality, length of stay in intensive care unit (ICU) and hospital. A total of 16 studies (four randomized studies and 12 cohort studies) were included in the meta-analysis. Compared with isolated ICP monitoring, the combined monitoring was associated with a higher favorable neurological outcome rate at 6 months (RR 1.33, 95% CI [1.17-1.51], P<0.0001, I2 = 0%), reduced long-term mortality (RR 0.72, 95% CI [0.59-0.87], P=0.0008, I2 = 2%). No significant difference was identified in the in-hospital mortality (RR 0.81, 95% CI 0.66 to 1.01, P=0.06, I2 = 32%), length of stay in ICU (MD 2.10, 95% CI [-0.37-4.56], P=0.10, I2 = 78%) and hospital (MD 1.07, 95% CI [-2.54-4.67], P=0.56, I2 = 49%) between two groups. However, the pooled results of randomized studies did not show beneficial effect of combined monitoring in favorable neurological outcome and long-term mortality. Currently, there is limited evidence to prove that the combined PbtO2 and ICP monitoring may contribute to improved neurological outcome and long-term mortality for patients with STBI. However, the benefit of combined monitoring should be further validated in more randomized studies.