Good Neurological Status Research Articles

Characteristics, Outcome and Prognostic Factors of Patients with Emergency Department Cardiac Arrest: A 14-Year Retrospective Study.

Introduction: Cardiac arrests are traditionally classified according to the setting in which they occur, including out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). However, cardiac arrests that occur in the emergency department (EDCA) could constitute a third category, due to the peculiar characteristics of the emergency department (ED). In recent years, the need to study EDCAs separately from other intra-hospital events has emerged. The aim of this study was to describe the characteristics and outcomes of a cohort of patients experiencing EDCA in an Italian hospital over a 14-year period. Methods: This was a single-centre retrospective observational study conducted in the ED of the Santa Croce e Carle Hospital in Cuneo, Italy. All adult patients who experienced EDCA between 1 January 2010 and 30 June 2023 were included. OHCA patients, those arriving in the ED with on-going resuscitation measures, patients with EDCA not undergoing resuscitation, and patients with post-traumatic cardiac arrest were excluded from the study. The main outcome of the study was survival at hospital discharge with a favourable neurological outcome. Results: 350 cases of EDCA were included. The median age was 78 (63-85) years, and the median Charlson Comorbidity Index score was 5 (3-6). A total of 35 patients (10%) survived to hospital discharge with a cerebral performance category (CPC) Score of 1-2; survival in the ED was 28.3%. The causes of cardiac arrests were identified in 212 cases (60.6%) and included coronary thrombosis (35%), hypoxia (22%), hypovolemia (17%), pulmonary embolism (11%), metabolic (8%), cardiac tamponade (4%), toxins (2%) and hypothermia (1%). Variables associated with survival with a favourable neurological outcome were young age, a lower Charlson Comorbidity Index, coronary thrombosis as the primary EDCA cause, and shockable presenting rhythm; however, only the latter was associated with the outcome in a multivariate age-weighted model. Conclusions: In a cohort of patients with EDCA over a period of more than a decade, the most frequent cause identified was coronary thrombosis; 10% of patients survived with a good neurological status, and the only factor associated with the best prognosis was presenting a shockable rhythm. EDCA should be considered an independent category in order to fully understand its characteristics and outcomes.

Predictors of functional outcomes following spinal meningioma surgery. A single-center retrospective experience of 59 cases

BackgroundTo better predict the postoperative functional outcomes of patients operated on for a spinal meningioma, we assessed: 1) the prevalence of good and poor postoperative functional outcomes following surgery; 2) the impact of age and frailty on postoperative functional outcomes. MethodsIn this retrospective cohort study, we screened adult patients operated on for a spinal meningioma from 2005 to 2022. Inclusion criteria were: 1) patients ≥18 years; 2) histopathological diagnosis of meningioma; 3) location to the cervical, thoracic or lumbar spine (foramen magnum meningioma excluded); 4) surgery as first-line treatment; and 5) available postoperative follow-up ≥1 year. Clinical outcomes were assessed using the modified McCormick scale preoperatively and at one-year of postoperative follow-up. ResultsIn this single institution experience of 59 cases, we found that: 1) surgical resection positively impacts patients’ functional outcomes, 91.2% either showing an improved or maintained good postoperative neurological status defined by a modified McCormick scale score ≤ II; 2) a good modified McCormick scale status was achieved in 84.2% of patients at one postoperative year; 3) 87.5% of patients who were not improved postoperatively maintained an overall good neurological status defined by a modified McCormick scale score ≤ II; and 4) frail or aged patients were not at a higher risk of poor postoperative functional outcomes. ConclusionSurgical resection positively impacts outcomes of patients operated for a spinal meningioma. Sex, presence of a meningioma-related myelopathy, extent of resection, and occurrence of surgery-related postoperative complications, but not age or frailty, predict postoperative functional outcomes.

Characterization and mid-term outcomes of current out-of-hospital cardiac arrest patients admitted to intensive cardiovascular care units

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Consell Català de Resuscitació. Background Out-of-hospital cardiac arrest (OHCA) accounts the 50% of cardiovascular deaths. Being aware of characteristics and outcomes of our OHCA population is important in order to apply measures in the weaker areas to improve the results of the process. Purpose To investigate current outcomes, at 6-month follow-up, of patients admitted to an Intensive Cardiac Care Unit (ICCU) in a mediterranean area during the 2020s. Current characteristics, prehospital management and factors related to outcomes were also analyzed. Methods PCR-Cat was a prospective observational multicentre registry. OHCA patients admitted to the ICCU of 8 hospitals were included from October/2020 to December/2021. Those who survived with good neurological status, no disabilities, and remained independent for usual life activities, were classified as Good Outcome (GO). Those patients who died or had a poor neurological status, with high dependency or rested in permanent vegetative status were classified as Poor Outcome (PO). A multinomial logistic regression was done to analyze the factors independently related to PO. Results 288 patients were included, only 50 (17.36%) were women. At 6-month follow-up, 48.95% of patients had GO. Most events happened in the first month (Figure 1). The cause of death was neurological in 72.9%. Patients with PO were significantly older (63.74 vs. 58.88, p=0.003) and had more comorbidities (Table 1A). The most frequent location was on a public space (54.84%) and most were witnessed (88.93%). Cardiopulmonary resuscitation maneuvers were initiated by a bystander in 69.18% until EMS arrival, being only 20.79% done by an experienced bystander. The medium no-flow time was low (2 min) but total time until ROSC was of 28 min. First rhythm was shockable in 80%, but an automatic external defibrillator was only used in 58% of cases. Statistically significant lower values of first pH and higher values of first lactate, glucose and creatinine were related to PO (Table 1B). Patients with PO had a higher APACHE II (26 vs. 20, p<0.001) and SOFA (10.39 vs. 7.14, p<0.001) scores at admission, and required a longer time on mechanical ventilation (6 vs. 3.5 days, p=0.001). The main cause of the OHCA was acute coronary syndrome (53.82%), followed by chronic coronary syndrome (7.64%) and dilated myocardiopathy (7.64%). In the multinomial logistic regression, older age (p=0.005), male sex (p=0.016), previous stroke (p=0.046), longer ROSC time (p<0.001) and non-shockable first rhythm (p<0.001) were independently related to PO. Receiving cardiopulmonary resuscitation maneuvers by an experienced bystander was related to a reduction of 17 min of ROSC (p=0.001). Conclusions Less than a half of patients admitted to an ICCU because of an OHCA had GO at 6-month follow-up. Age, male sex, previous stroke, longer ROSC time and non-shockable first rhythm were factors independently related to PO. Interventions addressed to reduce ROSC time are urgently needed.

A Study of Cerebral Venous Sinus Thrombosis with Special Reference to Newer Risk Predictors.

Cerebral venous thrombosis (CVT) is an uncommon and frequently unrecognized type of stroke that affects approximately five people per million annually, accounts for 0.5 to 1% of all strokes, and is more commonly seen in young individuals. The exact incidence of CVT in India remains unknown. The risk factors for venous thrombosis in general are linked classically to the Virchow's triad of stasis of the blood, changes in the vessel wall, and changes in the composition of the blood. There have been numerous studies evaluating long-term as well as short-term outcomes in the presence of these inflammatory mediators. They have been reported to be beneficial in predicting outcome and, hence, potentially in guiding management. Evaluation of prevailing risk factors associated with cerebral venous sinus thrombosis (CVST). Description of the distribution of newer inflammatory markers among the study population and their association with functional and neurologic outcome at 30 days following the occurrence of cerebral VST. Approval from the Institutional Review Board was obtained. Written informed consent was given by willing patients, explained in vernacular. Relevant details were obtained via a clinical history and laboratory values and imaging data obtained from the hospital's electronic health information system, which were then recorded in the proforma. No personal identifying data was collected. The sample size for this study was lower than originally planned, owing to the coronavirus disease 2019 (COVID-19) pandemic. The patients were called for follow-up after 1 month of the detection of VST, and their neurologic status was recorded on the Glasgow Coma Scale (GCS) and functional status on the modified Rankin Scale (mRS). Descriptive analysis of baseline characteristics was done. Mann-Whitney U and Kruskal-Wallis H tests of significant difference between means for nonparametric data were used. Linear regression was carried out on the variables found to differ significantly among subpopulations having good and poor neurologic outcomes. Receiver operating characteristic (ROC) curves were then derived for both outcome categories. The study enrolled 30 patients, with ages from 18 to 70 years, of which 19 (63.3%) were male and 11 (36.67%) were female. No risk factor was identified in 23.3% of cases. The most common risk factor was the presence of substance abuse. Among presenting features, headaches were the most common, followed by seizures and focal neurologic deficits (83.3, 30, and 23.3, respectively). Coexisting intraparenchymal hemorrhage was seen in 46.67% of patients, with the transverse sinuses most commonly involved (28.77%). The median neutrophil-to-lymphocyte ratio (NLR) was 3.415 [interquartile range (IQR) 2.634-5.637], with median platelet-to-lymphocyte ratio (PLR) 160.728 (IQR 107.728-227.776) and median systemic immune-inflammation index (SII) 1067.883 (IQR 509.694-1522.837). The NLR, PLR, and SII values were found to differ significantly among subgroups having good and poor neurologic outcome on the mRS. PLR and SII significantly differed among subgroups with venous involvement and among subgroups with good and poor neurologic status on GCS, on admission as well as 30-day follow-up. NLR, PLR, and SII values on admission showed a positive association with poor neurologic outcomes. Here, a significant correlation is seen between the values of complete blood count (CBC)-derived inflammatory markers on admission. Higher-powered studies are needed to assess the potential benefits of incorporating these markers in existing risk stratification models to improve their predictive accuracy.

Nonalcoholic fatty liver disease is an independent risk factor for ischemic stroke after revascularization in patients with Moyamoya disease: a prospective cohort study

BackgroundThe study aimed to investigate the association between nonalcoholic fatty liver disease (NAFLD) and ischemic stroke events after revascularization in patients with Moyamoya disease (MMD).MethodsThis study prospectively enrolled 275 MMD patients from September 2020 to December 2021. Patients with alcoholism and other liver diseases were excluded. NAFLD was confirmed by CT imaging or abdominal ultrasonography. Stroke events and modified Rankin Scale (mRS) scores at the latest follow-up were compared between the two groups.ResultsA total of 275 patients were enrolled in the study, among which 65 were diagnosed with NAFLD. Univariate logistic regression analysis showed that NAFLD (P = 0.029) was related to stroke events. Multivariate logistic regression analysis showed that NAFLD is a predictor of postoperative stroke in MMD patients (OR = 27.145, 95% CI = 2.031–362.81, P = 0.013). Kaplan-Meier analysis showed that compared with MMD patients with NAFLD, patients in the control group had a longer stroke-free time (P = 0.004). Univariate Cox analysis showed that NAFLD (P = 0.016) was associated with ischemic stroke during follow-up in patients with MMD. Multivariate Cox analysis showed that NAFLD was an independent risk factor for stroke in patients with MMD (HR = 10.815, 95% CI = 1.259–92.881, P = 0.030). Furthermore, fewer patients in the NAFLD group had good neurologic status (mRS score ≤ 2) than the control group (P = 0.005).ConclusionNAFLD was an independent risk factor for stroke in patients with MMD after revascularization and worse neurological function outcomes.

End-to-end revascularization between the occipital Artery(OA) and the p1 segment of posterior inferior cerebellar Artery(PICA) for a patient with posterior circulation ischemia via a far-lateral approach:2-Dimensional Operative video

Vertebral artery （VA）Aneurysms involving the origin of the posterior inferior cerebellar artery (PICA) ,occasionally, induce cerebellum and brainstem infarction due to intraluminal thrombus and calcific VA stenosis. At times, vessel occlusion and revascularization is necessary for successful obliteration of these aneurysms.2 The occipital artery (OA) is often the preferred donor graft for lesions of the posterior fossa. Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops , aberrant anatomy or p3 multiple perforators is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead. This video captures the dissection of the OA using an orientational anterograde harvesting technique and the end-to-end anastomosis of the OA to the PICA at the p1 segment. This was performed in a 56-year-old man who presented with posterior circulation ischemia from a fusiform aneurysm with calcific vertebral artery stenosis located at the origin of the right PICA. The patient tolerated the procedure well and suffered no major complications related to the operation. He did experience some mild, posterior neck rigidity at the time of his 6-month follow-up, likely due to nerve injury that occurred while harvesting the OA. Overall, the patient remains in good neurologic status 1 year after the operation. The operation proved the feasibility of end-to-end bypass in OA-p1 PICA.

Out-of-Hospital Cardiac Arrest Following the COVID-19 Pandemic

Out-of-hospital cardiac arrest (OHCA) health care provision may be a good indicator of the recovery of the health care system involved in OHCA care following the COVID-19 pandemic. There is a lack of data regarding outcomes capable of verifying this recovery. To determine whether return to spontaneous circulation, overall survival, and survival with good neurological outcome increased in patients with OHCA since the COVID-19 pandemic was brought under control in 2022 compared with prepandemic and pandemic levels. This observational cohort study was conducted to examine health care response and survival with good neurological outcome at hospital discharge in patients treated following OHCA. A 3-month period, including the first wave of the pandemic (February 1 to April 30, 2020), was compared with 2 periods before (April 1, 2017, to March 31, 2018) and after (January 1 to December 31, 2022) the pandemic. Data analysis was performed in July 2023. Emergency medical services (EMS) serving a population of more than 28 million inhabitants across 10 Spanish regions participated. Patients with OHCA were included if participating EMS initiated resuscitation or continued resuscitation initiated by a first responder. The pandemic was considered to be under control following the official declaration that infection with SARS-CoV-2 was to be considered another acute respiratory infection. The main outcomes were return of spontaneous circulation, overall survival, and survival at hospital discharge with good neurological outcome, expressed as unimpaired or minimally impaired cerebral performance. A total of 14 732 patients (mean [SD] age, 64.2 [17.2] years; 10 451 [71.2%] male) were included, with 6372 OHCAs occurring during the prepandemic period, 1409 OHCAs during the pandemic period, and 6951 OHCAs during the postpandemic period. There was a higher incidence of OHCAs with a resuscitation attempt in the postpandemic period compared with the pandemic period (rate ratio, 4.93; 95% CI, 4.66-5.22; P < .001), with lower incidence of futile resuscitation for OHCAs (2.1 per 100 000 person-years vs 1.3 per 100 000 person-years; rate ratio, 0.81; 95% CI, 0.71-0.92; P < .001). Recovery of spontaneous circulation at hospital admission increased from 20.5% in the pandemic period to 30.5% in the postpandemic period (relative risk [RR], 1.08; 95% CI, 1.06-1.10; P < .001). In the same way, overall survival at discharge increased from 7.6% to 11.2% (RR, 1.45; 95% CI, 1.21-1.75; P < .001), with 6.6% of patients being discharged with good neurological status (Cerebral Performance Category Scale categories 1-2) in the pandemic period compared with 9.6% of patients in the postpandemic period (RR, 1.07; 95% CI, 1.04-1.10; P < .001). In this cohort study, survival with good neurological outcome at hospital discharge following OHCA increased significantly after the COVID-19 pandemic.

Multiorgan failure in patients after out of hospital resuscitation: a retrospective single center study.

Information on extracerebral system dysfunction is important for assessing the needs of critically ill patients after cardiac arrest. To describe the prevalence of organ dysfunction and patient severity after out of hospital cardiac arrest (OHCA) using scores commonly used in intensive care and the association between these and mortality. Retrospective analysis of observational data collected in real time in a tertiary medical center where care withdrawal is mostly illegal. Adult patients after nontraumatic OHCA with ROSC who survived for more than two hours were included. Primary outcome-prevalence of organ failure, based on common definitions for organ dysfunction, in the 1days of hospitalization. Secondary outcomes-rates of survival to hospital discharge and survival with a good neurological outcome (CPC 1 or 2), and associations between organ dysfunction SOFA and APACHE-II scores and outcomes. Associations were assessed using fisher's exact test for categorical variables and Mann-Whitney and T test for continuous variables. Multivariable models were also constructed for all measurements showing associations in previous tests. For severity scores compatibility, we used receiver-operating curve (ROC). Overall 369 patients (median age 75years, 65% male) were included. Most arrests (64%) were witnessed, bystander CPR was provided in 15%. Median call to arrival time was 4min. The presenting rhythm was asystole in 48% and VT/VF in 22%. Cardiovascular causes of arrest predominated (48%, n = 178). The median length of hospitalization was 5days. Overall 28% of the patients (n = 98) survived to hospital discharge, mostly with a good neurological status (18.7%, n = 57). The rates of organ dysfunction were: hemodynamic instability 65% (n = 247), respiratory dysfunction 94% (n = 296), kidney dysfunction 70% (n = 259), hepatic dysfunction 14% (n = 50). The median SOFA score on day 1 was 9 and the median APACHE II score was 34. Modeling was limited by missing data. Neurological dysfunction (i.e. GCS and seizures) and kidney injury were consistently correlated with the outcomes in the multivariable models. Severity of critical illness assessed by above scoring systems correlated with mortality (all ROC curves had an AUC ranging between 0.728 and 0.849). Multiorgan failure is common after ROSC (1-4). Therefore, the management of patients after ROSC may require advanced multidisciplinary care. Scores describing the severity of critical illness should be routinely reported in resuscitation research. Our unique setting where withdrawal of care is illegal, allows assessment of extremely ill patients and may assist in defining margins for futility.

CT perfusion for Assessment of poor Neurological outcome in Comatose Cardiac Arrest Patients (CANCCAP): protocol for a prospective study

IntroductionCardiac arrest remains one of the most common causes of death with the majority occurring outside of hospitals (out of hospital cardiac arrest). Despite advancements in resuscitation management, approximately 50%...

Predictors of Postoperative Gain in Ambulatory Function After Decompressive Surgery for Metastatic Spinal Cord Compression.

Reports on the effects of timing of the surgery on the patient survival rate or the results of palliative laminectomy are limited. The aim of the study was to investigate the postoperative ambulatory status of neurologically impaired metastatic spinal cord compression (MSCC) patients who underwent laminectomy and evaluate predictors of postoperative ambulation recovery after laminectomy for MSCC. We included 175 patients who underwent decompressive surgery for MSCC. Changes in the Frankel grade (FG) were evaluated perioperatively. Among all patients, 113 were unable to walk preoperatively and were divided into two groups: 70 and 43 patients in the ambulation-regained and ambulation-not regained postoperatively groups, respectively. The percentage of patients eligible for postoperative chemotherapy and overall survival rate in each group were investigated. Furthermore, predictors of postoperative ambulation recovery after laminectomy for MSCC were examined. The most common primary tumor sites were the lung, prostate, and breast. FG improved with surgery in 80 cases, remained unchanged in 94 cases, and worsened in one case. In the ambulation-regained group, 70% were eligible for postoperative chemotherapy, while only 26% of the not-regained group were eligible for postoperative chemotherapy. The postoperative survival rate of the ambulation-regained group was significantly better than that of the not-regained group. Univariate predictors for not regaining the ability to walk were Karnofsky Performance Status ≤40 prior to surgery, FG B prior to surgery, and time to surgery since the inability to walk >48 h. Decompressive surgery benefits motor function postoperatively. Both good neurological status prior to surgery and prompt surgery for non-ambulatory MSCC are important predictors of improved functional outcome.

Association Between Admission Ionized Calcium Level and Neurological Outcome of Patients with Isolated Severe Traumatic Brain Injury: A Retrospective Cohort Study.

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Pathophysiological processes following initial insult are complex and not fully understood. Ionized calcium (Ca++) is an essential cofactor in the coagulation cascade and platelet aggregation, and hypocalcemia may contribute to the progression of intracranial bleeding. On the other hand, Ca++ is an important mediator of cell damage after TBI and cellular hypocalcemia may have a neuroprotective effect after brain injury. We hypothesized that early hypocalcemia might have an adverse effect on the neurological outcome of patients suffering from isolated severe TBI. In this study, we aimed to evaluate the relationship between admission Ca++ level and the neurological outcome of these patients. This was a retrospective, single-center, cohort study of all patients admitted between January 2014 and December 2020 due to isolated severe TBI, which was defined as head abbreviated injury score ≥ 4 and an absence of severe (abbreviated injury score > 2) extracranial injuries. The primary outcome was a favorable neurological status at discharge, defined by a modified Rankin Scale of 0-2. Multivariable logistic regression was performed to determine whether admission hypocalcemia (Ca++ < 1.16mmol L-1) is an independent predictor of neurological status at discharge. The final analysis included 201 patients. Hypocalcemia was common among patients with isolated severe TBI (73.1%). Most of the patients had mild hypocalcemia (1 < Ca++ < 1.16mmol L-1), and only 13 (6.5%) patients had Ca++ ≤ 1.00mmol L-1. In the entire cohort, hypocalcemia was independently associated with higher rates of good neurological status at discharge (adjusted odds ratio of 3.03, 95% confidence interval 1.11-8.33, p = 0.03). In the subgroup of 81 patients with an admission Glasgow Coma Scale > 8, 52 (64.2%) had hypocalcemia. Good neurological status at discharge was recorded in 28 (53.8%) of hypocalcemic patients compared with 14 (17.2%) of those with normal Ca++ (p = 0.002). In multivariate analyses, hypocalcemia was independently associated with good neurological status at discharge (adjusted odds ratio of 6.67, 95% confidence interval 1.39-33.33, p = 0.02). Our study demonstrates that among patients with isolated severe TBI, mild admission hypocalcemia is associated with better neurological status at hospital discharge. The prognostic value of Ca++ may be greater among patients with admission Glasgow Coma Scale > 8. Trials are needed to investigate the role of hypocalcemia in brain injury.

Interaction effect between prehospital hydration and initial cardiac rhythm in traumatic out-of-hospital cardiac arrest: a nationwide observational study

Traumatic cardiac arrest (TCA) is different in etiology compared to medical cardiac arrest. In case of TCA, it is important to initiate early fluid resuscitation. Initial cardiac rhythm serves as an indicator of outcomes in case of cardiac arrest. We aimed to find the association between prehospital hydration and outcomes of TCA according to initial cardiac rhythm. This is a retrospective, observational, cross-sectional study. An examination was undertaken involving patients afflicted with TCA within the timeframe of 2014 to 2019. Exposure was defined to encompass prehospital hydration; interactive exposure was categorized by initial cardiac rhythm (non-shockable vs. shockable); the primary outcome was defined as good neurological status at discharge, whereas the secondary outcome was defined as survival to discharge. Multivariable logistic regression analysis was used to calculate adjusted odds ratios (AORs) with 95% confidence intervals (CIs). A comprehensive analysis was conducted on a cumulative of 20,247 patients. Rates of good neurological status and survival to discharge were 0.2% and 8.3% (non-shockable rhythm group) and 3.0% and 16.7%(shockable rhythm group), respectively. However, rates of good neurological status and survival to discharge were 0.2% and 7.9% (non-prehospital hydration group) and 0.3% and 10.0% (hydration group), respectively. Compared to the non-hydration group, the AORs for good neurological status at discharge was 1.44 (95% CI: 0.77–2.69) for the hydration group. Moreover, compared to the non-shockable rhythm group, the AORs for good neurological status at discharge was 19.74 (95% CI: 10.46–27.26) in the shockable rhythm group. The interaction analysis conducted between prehospital hydration and initial rhythm unveiled the efficacy of prehospital hydration in promoting favorable survival to discharge outcomes in the non-shockable rhythm group. Therefore, prehospital hydration is recommended for those with TCA characterized by a non-shockable rhythm before transport from the incident location.

Traumatic Intracranial Hemorrhage on CT After Ground-Level Fall in Adult Patients Receiving Antithrombotic Therapy: A Retrospective Case-Control Study.

BACKGROUND. Antithrombotic medications may increase the risk and severity of traumatic intracranial hemorrhage (tICH) after minor head trauma. OBJECTIVE. The purpose of this study was to determine the frequency, distribution, and clinical course of tICH in patients receiving antithrombotic therapy who present with good neurologic status after a ground-level fall. METHODS. This retrospective study included 1630 patients (693 women and 937 men; mean age, 80.2 ± 12.7 [SD] years) who underwent head CT after presenting to the emergency department after a ground-level fall between January 1 and December 31, 2020; all patients had a Glasgow Coma Scale score of 14 or higher and no focal neurologic deficit. Patients with tICH were identified on the basis of clinical reports. In patients with tICH, images from initial head CT examinations were reviewed for characteristics of tICH, images from follow-up head CT examinations (performed within 24 hours) were reviewed for hematoma expansion, and clinical outcomes were extracted from medical records. Patients receiving antithrombotic therapy and control patients (those not receiving antithrombotic therapy) were compared. RESULTS. The antithrombotic therapy group included 954 patients (608 receiving anticoagulant therapy; 226, antiplatelet therapy; and 120, both therapies); the control group included 676 patients. A total of 63 patients (3.9%; 95% CI, 2.9-4.8%) had tICH. The antithrombotic therapy and control groups were not significantly different in terms of the frequency of tICH (4.4% vs 3.1%, p = .24), midline shift (10.0% vs 7.1%, p = .76) or regional mass effect (33.3% vs 14.3%, p = .19) on initial CT. Hematoma expansion on follow-up CT occurred in 11 of 42 patients (26.2%) in the antithrombotic group and one of 21 patients (4.8%) in the control group (p = .04). Two patients required neurosurgical intervention, and three deaths related to tICH occurred within 30 days; all five of these patients were receiving antithrombotic therapy. CONCLUSION. Antithrombotic therapy use was not associated with an increased frequency of tICH, although it was associated with an increased frequency of hematoma expansion at follow-up. CLINICAL IMPACT. In patients with good neurologic status after a ground-level fall, the findings suggest application of a similar strategy for selecting patients for initial head CT, regardless of antithrombotic therapy use; if initial head CT shows tICH, early follow-up head CT should be systematically performed in those receiving antithrombotic therapy, though it possibly should be deferred in other patients.

Veno-arterial extracorporeal membrane oxygenation for drug intoxications: A single center, 14-year experience.

Acute cardiovascular failure remains a leading cause of death in severe poisonings. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used as a rescue therapeutic option for those cases refractory to optimal conventional treatment. We sought to evaluate the outcomes after VA-ECMO used for drug intoxications in a single-center experience. We performed an observational analysis of our prospective institutional database. The primary endpoint was survival to hospital discharge. Between January 2007 and December 2020, 32 patients (mean age: 45.4 ± 15.8 years; 62.5% female) received VA-ECMO for drug intoxication-induced refractory cardiogenic shock (n = 25) or cardiac arrest (n = 7). Seven (21.8%) patients developed lower limb ischemia during VA-ECMO support. Twenty-six (81.2%) patients were successfully weaned after a mean VA-ECMO support of 2.9 ± 1.3 days. One (3.1%) patient died after VA-ECMO weaning for multiorgan failure and survival to hospital discharge was 78.1% (n = 25). In-hospital survivors were discharged from hospital with a good neurological status. Survival to hospital discharge was not statistically different according to sex (male = 75.0% vs. female = 80.0%; p = .535), type of intoxication (single drug = 81.8% vs. multiple drugs = 76.1%; p = .544) and location of VA-ECMO implantation (within our center = 75% vs. peripheral hospital using our Mobile Unit of Mechanical Circulatory Support = 100%; p = .352). Survival to hospital discharge was significantly lower in patients receiving VA-ECMO during on-going cardiopulmonary resuscitation (42.8% vs. 88.0%; p = .026). VA-ECMO appears to be a feasible therapeutic option with a satisfactory survival rate and acceptable complicationsrate in poisonings complicated by refractory cardiogenic shock or cardiac arrest.

A novel online calculator to predict nonroutine discharge, length of stay, readmission, and reoperation in patients undergoing surgery for intramedullary spinal cord tumors

BACKGROUND CONTEXTIntramedullary spinal cord tumors (IMSCTs) are rare tumors associated with significant morbidity and mortality. Surgical resection is often indicated for symptomatic lesions but may result in new neurological deficits and decrease quality of life. Identifying predictors of these adverse outcomes may help target interventions designed to reduce their occurrence. Nonetheless, most prior studies have employed population-level datasets with limited granularity. PURPOSETo determine independent predictors of nonroutine discharge, prolonged length of stay (LOS), and 30 day readmission and reoperation, and to deploy these results as a web-based calculator. STUDY DESIGNRetrospective cohort study PATIENT SAMPLEA total of 235 patients who underwent resection of IMSCTs at a single comprehensive cancer center. OUTCOME MEASURESNonroutine discharge, prolonged LOS, 30 day readmission, and 30 day reoperation METHODSPatients who underwent surgery from June 2002 to May 2020 at a single tertiary center were included. Data was collected on patient demographics, clinical presentation, tumor histology, surgical procedures, and 30 day readmission and reoperation. Functional status was assessed using the Modified McCormick Scale (MMS) and queried preoperative neurological symptoms included weakness, urinary and bowel dysfunction, numbness, and back and radicular pain. Variables significant on univariable analysis at the α≤0.15 level were entered into a stepwise multivariable logistic regression model. RESULTSOf 235 included cases, 131 (56%) experienced a nonhome discharge and 68 (29%) experienced a prolonged LOS. Of 178 patients with ≥ 30 days of follow-up, 17 (9.6%) were readmitted within 30 days and 13 (7.4%) underwent reoperation. Wound dehiscence (29%) was the most common reason for readmission. Nonhome discharge was independently predicted by older age (OR=1.03/year; p<.01), thoracic location of the tumor (OR=2.36; p=.01), presenting with bowel dysfunction (OR=4.09; p=.03), and longer incision length (OR=1.44 per level; p=.03). Independent predictors of prolonged LOS included presenting with urinary incontinence (OR=2.65; p=.05) or a higher preoperative white blood cell count (OR=1.08 per 103/μL); p=.01), while GTR predicted shorter LOS (OR=0.40; p=.02). Independent predictive factors for 30 day unplanned readmission included experiencing ≥1 complications during the first hospitalization (OR=6.13; p<.01) and having a poor (A-C) versus good (D-E) baseline neurological status on the ASIA impairment scale (OR=0.23; p=.03). The only independent predictor of unplanned 30 day reoperation was experiencing ≥1 inpatient complications during the index hospitalization (OR=6.92; p<.01). Receiver operating curves for the constructed models produced C-statistics of 0.67-0.77 and the models were deployed as freely available web-based calculators (https://jhuspine5.shinyapps.io/Intramedullary30day). CONCLUSIONSWe found that neurological presentation, patient demographics, and incision length were important predictors of adverse perioperative outcomes in patients with IMSCTs. The calculators can be used by clinicians for risk stratification, preoperative counseling, and targeted interventions.

Pravastatin may improve neurological outcome following low-grade aneurysmal subarachnoid hemorrhage

Statins may improve outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH) but randomized controlled trials, including all patients with aSAH whatever their clinical severity, were negative. We studied whether pravastatin improved neurologic outcome in patients with early good neurological status, whose prognosis is related to secondary lesions as delayed cerebral ischemia (DCI).We conducted a single-center study of cases and historical controls in a neurocritical care unit. We included consecutive patients with aSAH from 2011 to 2016 with early good neurological status defined by a WFNS score ≤ 3 on the third day. Patients treated before 2014 with oral pravastatin (40 mg/day for 14 days) as a standard of care were matched using propensity score to patients treated after 2014 without pravastatin. Good neurologic outcome was defined by a Glasgow Outcome Scale ≥ 4 at neurocritical care unit discharge.We included 270 patients (135 patients with pravastatin), mostly treated with coiling (94.1%).Demographic, initial and subacute features were the same in the 2 groups. More patients experienced good outcome in the pravastatin group than in the control group (94.8% vs 74.2%; OR 7.16 95% CI [3.07 – 16.72], p < 0.001). There was no difference in the occurrence of DCI in the 2 groups.In our study, outcome on neurocritical care discharge was better in patients with early good neurological status treated with pravastatin. Another randomized controlled trial should be conducted on this subtype of population.

National Surveillance of Pediatric Out-of-Hospital Cardiac Arrest in Korea: The 10-Year Trend From 2009 to 2018.

This study reports trends in pediatric out-of-hospital cardiac arrest (OHCA) and factors affecting clinical outcomes by age group. We identified 4,561 OHCA patients younger than 18 years between January 2009 and December 2018 in the Korean OHCA Registry. The patients were divided into four groups: group 1 (1 year or younger), group 2 (1 to 5 years), group 3 (6 to 12 years), and group 4 (13 to 17 years). The primary outcome was survival to hospital discharge, and the secondary outcomes were return of spontaneous circulation (ROSC) at the emergency department (ED) and good neurological status at discharge. Multivariate logistic analyses were performed. The incidence rate of pediatric OHCA in group 1 increased from 45.57 to 60.89 per 100,000 person-years, while that of the overall population decreased over the 10 years. The rates of ROSC at the ED, survival to hospital discharge, and good neurologic outcome were highest in group 4 (37.9%, 9.7%, 4.9%, respectively) and lowest in group 1 (28.3%, 7.1%, 3.2%). The positive factors for survival to discharge were event location of a public/commercial building or place of recreation, type of first responder, prehospital delivery of automated external defibrillator shock, initial shockable rhythm at the ED. The factors affecting survival outcomes differed by age group. This study reports comprehensive trends in pediatric OHCA in the Republic of Korea. Our findings imply that preventive methods for the targeted population should be customized by age group.

Mature ovarian teratoma-associated encephalitis

Introduction. Autoimmune encephalitis associated with ovarian teratoma is a serious and potentially fatal pathology. While this clinical entity is known to neurologists, the available literature rarely mentions the role of a gynecologist in diagnostic imagining and treatment. Although several months have passed from the onset of symptoms to surgical treatment, this case shows that even then a complete recovery is possible. Case presentation. The patient was a 28-year-old female, brought to the hospital because a sudden onset of unusual behavior ? an acute psychosis with suicidal thoughts and auditory hallucinations. Soon after the admission she became delirious, uncooperative and agitated. Blood check, neurological assessment and cranial computed tomography yielded normal results. Therefore, a psychiatric disorder was suspected. Electroencephalogram revealed a diffuse encephalitic insufficiency. As cerebrospinal fluid was negative for infections, the autoimmune etiology of the disease was suspected. Abdominal computer tomography showed a complex right ovarian mass measuring 50 ? 40 ? 30 mm, confirmed by vaginal ultrasound. Laparoscopy with right adnexectomy was performed. The pathohistological finding showed a mature teratoma. In the meantime, the result of the cerebrospinal fluid test came positive for Anti-N-Methyl-D-Aspartate antibodies. Six months after surgery, the patient was in a good mental and neurological status without symptoms. Conclusion. Gynecologists should be aware of the presence of ovarian tumors in encephalitis cases. A timely diagnosis of the underlying gynecological cause of a neurological condition, allows for prompt treatment and can remarkably improve clinical conditions and, thus, be lifesaving.

Impact of Specific Emergency Measures on Survival in Out-of-Hospital Traumatic Cardiac Arrest

The management of out-of-hospital traumatic cardiac arrest (TCA) for professional rescuers entails Advanced Life Support (ALS) with specific actions to treat the potential reversible causes of the arrest: hypovolemia, hypoxemia, tension pneumothorax (TPx), and tamponade. The aim of this study was to assess the impact of specific rescue measures on short-term outcomes in the context of resuscitating patients with a TCA. This retrospective study concerns all TCA patients treated in two emergency medical units, which are part of the Northern French Alps Emergency Network (RENAU), from January 2004 through December 2017. Utstein variables and specific rescue measures in TCA were compiled: fluid expansion, pelvic stabilization, tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at Day 30 with good neurological status (Cerebral Performance Category [CPC] score CPC 1 and CPC 2). In total, 287 resuscitation attempts in TCA were included and 279 specific interventions were identified: 262 fluid expansions, 41 pelvic stabilizations, five tourniquets, and 175 bilateral thoracostomies (including 44 with TPx). Among the standard resuscitation measures to treat the reversible causes of cardiac arrest, this study found that bilateral thoracostomy and tourniquet application on a limb hemorrhage improve survival in TCA. A larger sample for pelvic stabilization is needed.

ML-18 High-dose chemotherapy supported by autologous stem cell transplant in relapsed and refractory primary CNS lymphoma

While whole brain radiation therapy (WBRT) has been performed as consolidation therapy in primary central nervous system lymphoma (PCNSL), high-dose chemotherapy supported by autologous stem cell transplant (HDC/ASCT) is widely investigated today as an alternative treatment strategy, given the high risk for radiation-induced neurotoxicity in WBRT. Various conditioning regimens have been investigated in phase II trials, which report non-inferiority of HDC/ASCT in efficacy and preservation of neurocognitive function in comparison with WBRT. Besides its promising efficacy, treatment-related deaths are reported in 11% in patients treated by a conditioning regimen using thiotepa, busulfan and cyclophosphamide (TBC), which raises a concern for safety. Among several conditioning regimens, analysis using registry data of Japan Society for Hematopoietic Cell Transplantation has revealed that the use of conditioning regimens containing thiotepa was a positive factor for longer PFS. According to the result of a phase I trial in Japan which investigated HDC/ASCT using thiotepa and busulfan (BuTT), thiotepa was approved by the pharmaceuticals and medical devices agency (PMDA) on March 2020. In comparison with the TBC regimen, cyclophosphamide is omitted, and the dose of thiotepa is lower (250 mg/m2, 3 days in TBC; 5 mg/kg, 2 days in BuTT) in BuTT, therefore BuTT could be less toxic in comparison with TBC, and no treatment-related deaths were observed in the phase I study in Japan. Further investigation on the efficacy and safety of BuTT in actual clinical practice is warranted. We have constituted a multi-disciplinary team in our institution in order to perform HDC/ASCT using BuTT in relapsed/refractory PCNSL. Treatment indications are as follows; 65 years old or younger, previously treated by rituximab, methotrexate, procarbazine and vincristine (R-MPV), good organ function and neurological status. Future directions along with preliminary treatment results will be discussed at the meeting.