Neurological Outcome In Patients Research Articles

Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study

BackgroundThe optimal hemoglobin (Hb) threshold to trigger red blood cell transfusions (RBCT) in subarachnoid hemorrhage (SAH) patients is unclear. This study evaluated the impact of liberal versus restrictive transfusion strategies on neurological outcome in patients with SAH.MethodsThis is a pre-planned secondary analysis of the “TRansfusion Strategies in Acute brain INjured Patients” (TRAIN) study. We included all SAH patients from the original study that were randomized to receive RBCT when Hb levels dropped below 9 g/dL (liberal group) or 7 g/dL (restrictive group). The primary outcome was an unfavorable neurological outcome at 180 days, defined by a Glasgow Outcome Scale Extended score of 1–5.ResultsOf the 190 SAH patients in the trial, 188 (98.9%) had data available for the primary outcome, with 86 (45.3%) in the liberal group and 102 (53.6%) in the restrictive group. Patients in the liberal group were older than in the restrictive group, but otherwise had similar baseline characteristics. Patients in the liberal group received more RBCT and showed higher Hb levels over time. At 180 days, 57 (66.3%) patients in the liberal group and 78 (76.4%) in the restrictive group had unfavorable outcomes (risk ratio, RR 0.87; 95% confidence intervals, 95% CI 0.71–1.04). Patients in the liberal group had a significantly lower risk of cerebral ischemia (RR 0.63; 95% CI 0.41–0.97). In a multivariate analysis, randomization to the liberal group was associated with a lower risk of unfavorable outcome (RR 0.83, 95% CI 0.70–0.99).ConclusionsA liberal transfusion strategy was not associated with a lower incidence of unfavorable outcome after SAH when compared to a restrictive strategy. However, in a multivariable analysis adjusted for confounders randomization to the liberal group was associated with lower risk of unfavorable outcome. The occurrence of cerebral ischemia was significantly lower in the liberal transfusion strategy group.Trial registrationClinicalTrials.gov number—NCT02968654 registered on November 16th, 2016.

Medical and Early Developmental Outcomes for Patients with Congenital Ventriculomegaly

Introduction: This study evaluated whether comorbidities such as genetic conditions, other congenital anomalies, infection, and other exposures impact the mortality rate and/or neurologic outcomes of patients with congenital ventriculomegaly. Methods: This was a retrospective cohort study that assessed the mortality rate and developmental delay of 91 patients diagnosed with congenital ventriculomegaly followed at Cincinnati Children’s Hospital Medical Center between January 1, 2010, and December 31, 2020. Results: Of the 91 patients included in the study, 20 (22.0%) had a genetic diagnosis. The mortality rate was higher for patients with a genetic diagnosis compared to those without a genetic diagnosis (p = 0.022), as was the rate of developmental delay (p = 0.026). The presence of comorbidities (confirmed genetic condition, confirmed maternal exposures or infections, and/or additional anomalies) was not associated with an increased risk of mortality nor developmental delay. Conclusions: Patients diagnosed with congenital ventriculomegaly and a genetic condition have a significantly higher risk of early mortality and developmental delay compared to those without a genetic diagnosis. Therefore, diagnostic genetic testing should be considered after identification of congenital ventriculomegaly to facilitate counseling about prognosis and care management.

Comparative Efficacy of Extracorporeal Versus Conventional Cardiopulmonary Resuscitation in Adult Refractory Out-of-Hospital Cardiac Arrest: A Retrospective Study at a Single Center.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) has the potential to improve neurological outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA), offering an alternative to conventional cardiopulmonary resuscitation (CCPR). However, its effectiveness in OHCA remains controversial despite advancements in resuscitation techniques. Methods: This retrospective single-center study compared neurological outcomes and 30-day survival between ECPR and CCPR patients from January 2014 to January 2022. Patients aged 18-75 with witnessed OHCA, minimal no flow and low flow times, and cardiac arrests occurring at home or in public places were included. All patients were transported directly to our institution, a tertiary medical center serving the southeastern region of Seoul, where extracorporeal membrane oxygenation implantation was consistently performed in the emergency department. Neurological outcomes were assessed using Cerebral Performance Category scores, with good outcomes defined as scores of 1-2. Statistical analyses included logistic regression models and Kaplan-Meier survival curves, adjusted for confounders using inverse probability of treatment weighting. Results: ECPR was associated with significantly better neurological outcomes than CCPR (p < 0.001). Factors predicting poor outcomes included older age and longer low flow times, while male sex and shockable rhythms were protective. No significant difference was found in 30-day survival between the ECPR and CCPR groups, although a trend toward better survival was noted with ECPR. Conclusions: ECPR may improve neurological outcomes in patients with refractory OHCA compared to CCPR, although it does not significantly affect 30-day survival. Further studies are necessary to validate these findings and explore the long-term impacts of ECPR.

Diffusion Tensor Imaging as Neurologic Predictor in Patients Affected by Traumatic Brain Injury: Scoping Review.

Background: Diffusion tensor imaging (DTI), a variant of Diffusion Weighted Imaging (DWI), enables a neuroanatomical microscopic-like examination of the brain, which can detect brain damage using physical parameters. DTI's application to traumatic brain injury (TBI) has the potential to reveal radiological features that can assist in predicting the clinical outcomes of these patients. What is the ongoing role of DTI in detecting brain alterations and predicting neurological outcomes in patients with moderate to severe traumatic brain injury and/or diffuse axonal injury? Methods: A scoping review of the PubMed, Scopus, EMBASE, and Cochrane databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The aim was to identify all potentially relevant studies concerning the role of DTI in TBI. From an initial pool of 3527 publications, 26 articles were selected based on relevance. These studies included a total of 729 patients with moderate to severe TBI and/or diffuse axonal injury. DTI parameters were analyzed to determine their relationship with neurological outcomes post-TBI, with assessments of several brain functions and regions. Results: The studies included various DTI parameters, identifying significant relationships between DTI variations and neurological outcomes following TBI. Multiple brain functions and regions were evaluated, demonstrating the capability of DTI to detect brain alterations with higher accuracy, sensitivity, and specificity than MRI alone. Conclusions: DTI is a valuable tool for detecting brain alterations in TBI patients, offering enhanced accuracy, sensitivity, and specificity compared to MRI alone. Recent studies confirm its effectiveness in identifying neurological impairments and predicting outcomes in patients following brain trauma, underscoring its utility in clinical settings for managing TBI.

Optimal timing for epinephrine administration in adult patients with out-of-hospital cardiac arrest: A retrospective observational study.

This study aimed to clarify the appropriate timing for epinephrine administration in adults with out-of-hospital cardiac arrest (OHCA), particularly those cases with nonshockable rhythms, by addressing resuscitation time bias. We performed a retrospective observational study utilizing a multicenter OHCA registry involving 95 hospitals in Japan between June 2014 and December 2020. We included patients with OHCA and nonshockable rhythms who received epinephrine during resuscitation. The primary and secondary outcomes were favorable 30-day neurological status and survival, respectively. A favorable neurological outcome was defined as a cerebral performance category score of 1 or 2. The time from emergency medical service (EMS) personnel contact to epinephrine administration was categorized in 5-min intervals. We used the Fine-Gray regression to calculate the time-dependent propensity score in each group. After risk set matching, we employed a generalized estimating equation (GEE) to adjust for within-patient clustering. A total of 36,756 patients were included in the analysis. When involving timing variables and GEE, epinephrine administration significantly affected favorable 30-day neurological status at 1-5 and 6-10 min, with risk ratios (RR; 95% confidence intervals [CIs]) of 9.36 (1.19-73.7) and 3.67 (1.89-7.14), respectively. Epinephrine administration significantly affected 30-day survival at 1-5, 6-10, 11-15, and 16-20 min, with RRs (95% CIs) of 2.33 (1.41-3.85), 2.09 (1.65-2.65), 1.64 (1.32-2.05), or 1.70 (1.29-2.25), respectively. Epinephrine administration within 10 min of EMS personnel contact may be associated with favorable neurological outcomes in patients with OHCA and nonshockable rhythms.

Contralateral Neurovascular Coupling in Patients with Ischemic Stroke After Endovascular Thrombectomy.

Neurovascular coupling (NVC) refers to the process of aligning cerebral blood flow with neuronal metabolic demand. This study explores the potential of contralateral NVC-linking neural electrical activity on the stroke side with cerebral blood flow velocity (CBFV) on the contralesional side-as a marker of physiological function of the brain. Our aim was to examine the association between contralateral NVC and neurological outcomes in patients with ischemic stroke following endovascular thrombectomy. We concurrently recorded the CBFVs of the middle cerebral arteries and electroencephalographic (EEG) signals of patients after endovascular thrombectomy. We employed phase-amplitude cross-frequency coupling to quantify the contralateral coupling between EEG activity on the stroke side and CBFV on the contralesional side. Key neurological outcomes were measured, including changes in National Institute of Health Stroke Scale (NIHSS) scores, infarct volume progression over 7days, and modified Rankin Scale scores at 90days. A total of 52 study participants were enrolled in our study (mean age 61.5 ± 10.4years; 90.4% male; median preprocedural NIHSS score 14 [interquartile range 10-17]). We successfully computed contralateral NVC in 48 study participants. A significant association emerged between contralateral coupling and improvements in NIHSS scores over 7days (theta band, P = 0.030) and in infarct volume progression (delta band, P = 0.001; theta band, P = 0.013). Stronger contralateral NVC in the delta and theta bands correlated with better outcomes at 90days (adjusted odds ratio for delta 7.53 [95% confidence interval 1.13-50.30], P = 0.037; adjusted odds ratio for theta 6.36 [95% confidence interval 1.09-37.01], P = 0.039). A better contralateral coupling between stroke-side EEG and contralesional CBFV is associated with favorable neurological outcomes, suggesting that contralateral NVC analysis may aid in assessing brain function after recanalization. Replication with a deeper understanding of the mechanisms is needed before clinical translation.

Intra-arterial Alteplase Thrombolysis After Successful Thrombectomy for Acute Ischemic Stroke in the Posterior Circulation (IAT-TOP): Study protocol and rationale.

The Chemical Optimization of Cerebral Embolectomy (CHOICE) trial suggested that the administration of intra-arterial alteplase after successful endovascular thrombectomy (EVT) may improve neurological outcomes in patients with acute ischemic stroke due to large-vessel occlusion (AIS-LVO) in the anterior circulation. However, the use of adjunctive intra-arterial alteplase following successful EVT in acute posterior circulation stroke remains unexplored. This study aims to investigate the efficacy and safety of intra-arterial alteplase after successful EVT for AIS-LVO in the posterior circulation. To detect an estimated 15% difference in the primary outcome between the two groups, a total of 376 patients will be enrolled. This sample size allows for 80% power and a 5% significance level, with an interim analysis planned after half of the sample (188 patients) has completed a 90-day follow-up. The Intra-arterial Alteplase Thrombolysis After Successful Thrombectomy for Acute Ischemic Stroke in the Posterior Circulation (IAT-TOP) trial is a multicenter, prospective, randomized clinical trial using an open-label treatment design with blinded endpoint assessment (PROBE) conducted in China. Patients with acute basilar artery occlusion will be randomly assigned in a 1:1 ratio to receive either intra-arterial alteplase (0.225 mg/kg; maximum dose, 22.5 mg) or standard care following successful thrombectomy (defined as expanded thrombolysis in cerebral infarction [eTICI] ⩾ 2b50). The primary outcome is the modified Rankin Scale (mRS) score of 0-2 at 90 days. Key secondary outcomes include changes in eTICI scores after intra-arterial thrombolysis (in the experimental group), mRS 0-3 at 90 days, ordinal shift analysis of mRS at 90 days, early neurological improvement at 48 h, and improvement in National Institutes of Health Stroke Scale (NIHSS) scores at 48 h and 7 days or discharge. Safety outcomes include symptomatic intracranial hemorrhage (sICH) rates at 48 h, 90-day mortality, non-intracranial hemorrhagic complications, and non-hemorrhagic serious adverse events. The IAT-TOP trial will provide crucial evidence regarding the potential benefits of adjunctive intra-arterial alteplase in patients with AIS-LVO in the posterior circulation following successful thrombectomy. ClinicalTrials.gov NCT05897554.

What is the Optimal Management of Metastatic Spine Patients With Intermediate Spinal Instability Neoplastic Scores: To Operate or Not to Operate?

Systematic review. In patients with extradural metastatic spine disease, we sought to systematically review the outcomes and complications of patients with intermediate Spinal Instability Neoplastic Score (SINS) lesions undergoing radiation therapy, percutaneous interventions, minimally invasive surgeries, or open spinal surgeries. Following PRISMA guidelines for systematic reviews, MEDLINE, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews and the Cochrane Center Register of Controlled Trials were queried for studies that reported on SINS intermediate patients who underwent: 1) radiotherapy, 2) percutaneous intervention, 3) minimally invasive, or 4) open surgery. Dates of publication were between 2013-22. Patients with low- or high-grade SINS were excluded. Outcome measures were pain score, functional status, neurological outcome, ambulation, survival, and perioperative complications. Thirty-nine studies (n = 4554) were included that analyzed outcomes in the SINS intermediate cohort. Radiotherapy appeared to provide temporary improvement in pain score; however, recurrent pain led to surgery in 15%-20% of patients. Percutaneous vertebral augmentation provided improvement in pain. Minimally invasive surgery and open surgery offered improvement in pain, quality of life, neurological, and ambulatory outcomes. Open surgery may be associated with more complications. There was limited evidence for radiofrequency ablation. In the SINS intermediate group, radiotherapy was associated with temporary improvement of pain but may require subsequent surgery. Both minimally invasive surgery and open spinal surgery achieved improvements in pain, quality of life, and neurological outcomes for patients with spine metastases. Open surgery may be associated with more complications.

Effect Size of Targeted Temperature Management in Pediatric Patients with Post-Cardiac Arrest Syndrome According to the Severity.

Few studies have investigated the differential effects of targeted temperature management (TTM) according to the severity of the condition in pediatric patients with post-cardiac arrest syndrome (PCAS). This study was aimed at evaluating the differential effects of TTM in pediatric patients with PCAS according to a risk classification tool developed by us, the rCAST. We used data from a nationwide prospective registry for out-of-hospital cardiac arrest (OHCA) patients in Japan. We classified eligible pediatric PCAS patients (aged ≤ 18 years) into quintiles based on their rCAST scores and evaluated the effect of TTM on the neurological outcomes in each severity group. Then, focusing on the severity group that appeared to benefit from TTM, we also evaluated the effect of TTM by propensity score analysis. Good neurological outcome was defined as a score on the Cerebral Performance Category or Pediatric Cerebral Performance Category scale of ≤2 at 30 days. Among 1526 OHCA pediatric patients enrolled in the registry, the data of 307 PCAS patients were analyzed. None of the patients in the fifth quintile (rCAST ≥ 18.5) showed a good neurological outcome, regardless of whether they received TTM or not (0% [0/20] vs. 0% [0/73]). The propensity score analysis showed that TTM was significantly associated with a good neurological outcome in patients with rCAST scores in the first to fourth quintile (odds ratio: 1.21 [1.04-1.40], p = 0.014). TTM was significantly associated with good neurological outcomes in pediatric PCAS patients with rCAST scores of ≤18.0.

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

BackgroundPatients 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...

Evaluation of the efficacy and safety of cytoflavin as a neuroprotector based on a systematic review

Introduction. Currently, neurological diseases occupy one of the first places in terms of the DALY (Disability-adjusted life year) index and are the second cause of death in the world. There is a tendency towards rejuvenation and an increase in morbidity. Drug therapy aimed at neuroprotection and improving the restoration of neurological functions according to clinical recommendations includes a succinate-containing drug – Cytoflavin. However, these recommendations are based on a very limited number of studies (4 studies for cytoflavin). Due to the huge amount of work in the field of the use of succinate-containing drugs as neuroprotectors, the lack of quantitative assessment of research results, it seems promising to conduct systematic reviews and meta-analysis in this area.Aim. Evaluation of the efficacy and safety of cytoflavin as a neuroprotector based on a systematic review.Materials and methods. A systematic review of the research results was conducted according to the criteria of PRISMA 2020. The search for publications was carried out using PubMed, Medline databases, as well as Russian scientific electronic libraries eLibrary.Ru and RSCI. Materials were also searched in the systems of the national and international registry of clinical trials.Results and discussion. The review included 18 publications, including a description of the therapy of 10 pathologies of neurological origin. The largest part of the studies was devoted to the treatment of ischemic stroke (n = 4/18; 22.22 %) and manifestations of cognitive dysfunction (n = 5/18; 27.78 %). The pool of materials included studies of various designs, but most of them were represented by open comparative randomized/non-randomized studies. An analysis of the sources showed that the positive effect of the use of cytoflavin and the expediency of including its therapy regimen is noted in all publications. However, many studies have low statistical power due to the small sample sizes of patients, their heterogeneity and incompleteness of providing treatment data and the lack of randomization.Conclusion. According to the results of most clinical studies, it has been shown that the use of cytoflavin is safe, and its administration in neurological diseases of various origins is advisable due to a decrease in the frequency of adverse neurological outcomes in patients. For an objective research result, a meta-analytical assessment of the publications included in the review is required.

A Machine Learning-Based Decision Support System for the Prognostication of Neurological Outcomes in Successfully Resuscitated Out-of-Hospital Cardiac Arrest Patients.

Background/Objectives: This study uses machine learning and multicenter registry data for analyzing the determinants of a favorable neurological outcome in patients with out-of-hospital cardiac arrest (OHCA) and developing decision support systems for various subgroups. Methods: The data came from the Korean Cardiac Arrest Research Consortium registry, with 2679 patients who underwent OHCA aged 18 or above with the return of spontaneous circulation (ROSC). The dependent variable was a favorable neurological outcome (Cerebral Performance Category score 1-2), and 68 independent variables were included, e.g., first monitored rhythm, in-hospital cardiopulmonary resuscitation (CPR) duration and post-ROSC pH. A random forest was used for identifying the major determinants of the favorable neurological outcome and developing decision support systems for the various subgroups stratified by the major variables. Results: Based on the random forest variable importance, the major determinants of the OHCA patient outcomes were the in-hospital CPR duration (0.0824), in-hospital electrocardiogram on emergency room arrival (0.0692), post-ROSC pH (0.0579), prehospital ROSC before emergency room arrival (0.0565), coronary angiography (0.0527), age (0.0415), first monitored rhythm (EMS) (0.0402), first monitored rhythm (community) (0.0401), early coronary angiography within 24 h (0.0304) and time from scene arrival to CPR stop (0.0301). It was also found that the patients could be divided into six subgroups in terms of their prehospital ROSC and first monitored rhythm (EMS), and that a decision tree could be developed as a decision support system for each subgroup to find the effective cut-off points regarding the in-hospital CPR duration, post-ROSC pH, age and hemoglobin. Conclusions: We identified the major determinants of favorable neurological outcomes in successfully resuscitated patients who underwent OHCA using machine learning. This study demonstrates the strengths of a random forest as an effective decision support system for each stratified subgroup (prehospital ROSC and first monitored rhythm by EMS) to find its own optimal cut-off points for the major in-hospital variables (in-hospital CPR duration, post-ROSC pH, age and hemoglobin).

Effect of hypercapnia on neurologic outcomes after cardiac arrest: A systematic review and meta-analysis.

Brain injury often occurs after cardiac arrest, and the regulation of PaCO2 plays a crucial role in mediating cerebral blood flow. The current guidelines recommend maintaining normocapnia through ventilation in post-arrest patients. However, the effects of hypercapnia on neurological outcomes remain controversial. To address this issue, we undertook a meta-analysis to compare the effects of hypercapnia and normocapnia on the neurological outcomes in patients with cardiac arrest. As of December 5, 2023, we conducted a search on eligible studies, including EMBASE, PubMed, and WOS databases. Our primary outcome of interest was a good neurological outcome, and two authors independently screened the studies and extracted relevant data. For analysis, a fixed effects model was used when the I2 values were less than 50%, whereas a random effects model was used for higher I2 values. From the 2137 studies initially identified, seven studies involving 2770 patients were ultimately included. Compared with normocapnia, hypercapnia significantly improved the neurological outcomes of patients with cardiac arrest (OR 0.73; 95% CI 0.56-0.96; P=0.02). According to the subgroup analysis, the hypercapnic group achieved better neurological outcomes in the short-term than did the normocapnia group (OR 0.61; 95% CI 0.42-0.88; P=0.008), whereas no significant difference was observed in long-term (OR 0.91; 95% CI 0.76-1.10; P=0.35). Moreover, there was no significant difference in mortality between the two groups (OR 1.03; 95% CI 0.65-1.63; P=0.91). Our results suggest that hypercapnia is associated with a good neurological prognosis, especially in the short-term setting. However, further well-powered randomized controlled trials are necessary to confirm the optimal PaCO2 targets. CRD42023457027. Registered 3 September 2023.

Total cholesterol and bilirubin levels are associated with neurologic outcomes in patients with out-of-hospital cardiac arrest.

Assessing the neurologic outcomes of patients who experience out of hospital cardiac arrest (OHCA) is challenging. Neurologic outcomes were evaluated using initial nutrition related biochemical markers. We used data from a multicentre retrospective observational study, the Korean Cardiac Arrest Resuscitation Consortium (KoCARC) registry. Among the 666 patients, 217 had good neurologic outcomes, while 449 had poor neurologic outcomes. Multivariate logistic regression and classification and regression tree (CART) analyses were employed. In the multivariate logistic regression analysis, total cholesterol ≥ 158.5mg/dL, total bilirubin ≥ 0.265mg/dL, Sodium < 142.1mEq/L, AST < 200.5 U/L and were identified as significant biomarkers for good neurologic outcomes. In the CART analysis, total cholesterol ≥ 158.5mg/dL and total bilirubin ≥ 0.365mg/dL were found to be significant indicators. In additional analysis, when the total bilirubin level ranged from 0.6 to 0.7mg/dL, the highest rate of a good neurologic outcome was observed at 44.6%, whereas levels below or above this range gradually indicated a lower rate of a good neurologic outcome. We propose that total cholesterol and total bilirubin levels could serve as valuable indicators for predicting neurologic outcomes in patients with OHCA.

Prognostic value of gray–white matter ratio measured by brain MRI-based CT structures in comatose patients after cardiac arrest

BackgroundPost-cardiac arrest care advancements have improved resuscitation outcomes, but many survivors still face severe neurological deficits or death from brain injury. Herein, we propose a consistent prognosis prediction approach using magnetic resonance imaging (MRI) to analyze anatomical regions represented by the gray and white matter, and subsequently apply it on computed tomography (CT) to calculate the gray–white matter ratio (GWR). We compared this novel method with traditional measures to validate its ability to predict the prognosis of patients resuscitated after cardiac arrest. MethodsConducted retrospectively at two South Korean tertiary university hospitals from January 2018 to December 2022, the study included adult cardiac arrest survivors treated with therapeutic target temperature management. Patients underwent brain CT within 2 h and brain MRI within 3 days of return of spontaneous circulation. The outcome was the neurological status at discharge. Statistical analyses included receiver operating characteristic curve analysis and determining cutoff values to predict poor neurological outcomes. ResultsOverall, 51 of the 421 adult comatose cardiac arrest survivors examined met the inclusion criteria. Among these, 33 and 18 exhibited good and poor neurological outcomes, respectively. Demographic and cardiac arrest characteristics were compared between the two groups, revealing significant differences. Analyses of gray and white matter attenuation and GWR measurements highlighted significant differences between the good and poor outcome groups. ConclusionOur study introduces a novel method for measuring GWR using MRI-based brain CT, demonstrating superior prognostic accuracy in predicting neurological outcomes in patients with post-cardiac arrest syndrome compared to traditional methods.

Reply to: “Lactate-to-albumin ratio in predicting neurological outcomes in patients who have survived cardiac arrest”

Reply to: “Lactate-to-albumin ratio in predicting neurological outcomes in patients who have survived cardiac arrest”

The effect of intra-aortic balloon pump on survival and neurological outcome in patients treated with extracorporeal cardiopulmonary resuscitation: A meta-analysis and systematic review

IntroductionExtracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used to treat refractory cardiac arrest, although with variable results in survival and neurological outcomes. The intra-aortic balloon pump (IABP) showed mixed effects on survival in veno-arterial extracorporeal membrane oxygenation. Furthermore, the impact of IABP on survival and neurological outcomes in ECPR recipients has yet to be fully investigated. MethodsWe searched relevant databases for studies concerning ECPR recipients and intra-aortic balloon pump with information on survival and neurological outcomes. The inverse variance method (95 % confidence intervals) was used to determine the odds ratios of outcomes. We decided on a priori use of the random-effects model with the Hartung-Knapp adjustment. ResultsWe included in our analysis nine cohort studies dealing with a total of 4994 patients. The association of IABP with ECPR was associated with a survival benefit compared to ECPR alone: 1029/3124 (32.9 %) patients survived in the ECPR+IABP group versus 379/1870 (20.2 %) in the ECPR group, OR 1.94, 95 % CI [1.36 to 2.77]. Survival with good neurological outcome was analyzed in 4 studies for 4018 patients. The association of ECPR and IABP was associated with a not significant advantage in survival with favorable neurological outcome compared with ECPR alone: 555/2687 (20.7 %) patients with good neurological outcome in the group of ECPR+IABP versus 149/1331 (11.2 %) patients in the group of ECPR, OR 1.33, 95 % CI [0.61 to 2.92]. ConclusionsThe association of IABP and ECPR significantly increases survival rates compared to ECPR alone. Nevertheless, the impact on favorable neurological outcomes remains uncertain.

Long-term neurological outcome in patients presenting with encephalitis.

Advances in encephalitis research have improved the definition and management of encephalitis during the acute phase. Still, little is known about long-term outcomes in different subtypes of encephalitis. To analyze the prevalence and predictors of long-term clinical outcomes in different subtypes of encephalitis. All patients discharged from a tertiary hub for acute neurology with a confirmed diagnosis of encephalitis were included. Encephalitis were classified into autoimmune (AE), infectious (IE) and of unknown origin (UE) according to guidelines. Long-term neurological sequelae were evaluated using a 16-item questionnaire assessing severity and frequency of neurological symptoms, disability was scored using the expanded Disability status scale (EDSS). Long-term symptoms distribution and predictors were evaluated using univariate and multivariate regression models. Seventy out 105 survived patients were included (AE n = 30, IE n = 12, UE n = 28). Disability at discharge was worse in AE compared to UE (p = 0.018). Additionally, AE had a higher risk of relapse (n = 8 AE, n = 1 UE, p = 0.001). 36 patients (51,4%) showed significant disability according to EDSS; whereas 72,9% reported a significant neurological long-term sequela, including cognitive deficits (50,0%), depression (41,4%) and numbness (21,0%). Older age and abnormal MRI at onset were the strongest predictors of long-term severe sequelae. independently from the subtype of encephalitis. Long-term sequelae are common in encephalitis, and are associated with MRI abnormalities, premorbid disability, and older age at onset. Further longitudinal studies are needed to focus on biological and clinical predictors, to identify patients who might benefit from cognitive and behavioral training after discharge.

Mild intracerebral bleeding does not adversely affect survival and neurological outcome of surgical therapy for left-sided infective endocarditis

Abstract Background Intracerebral bleeding (IB) is a serious condition that requires increased attention and has implications for treatment options. For patients with infective endocarditis (IE), current guidelines recommend postponing surgery if IB is present. IB can be classified into four relevant groups (following European Cooperative Acute Stroke Study and Heidelberger Bleeding classification): hemorrhagic transformation (HT) 1 and 2, and parenchymal hemorrhage (PH) 1 and 2. PH2 is the only IB with neurological deterioration. These classifications were originally introduced for stroke patients following thrombolysis but without IE. The hypothesis tested in our study is that IB may influence IE treatment and thus outcome. Method Patients were retrospectively identifyied who were operated for left-sided IE, neuroradiologists re-evaluated and classified preoperative cerebral imaging for any IB. Outcome was quantified using the modified Rankin score (mRS), and mRS were extracted from the patients’ hospital chart at admission and by follow-up telephone call (FU), also including mortality. To ensure that the influence of IB was comparable, patients with IB (IB+) were propensity matched (EuroScore 2, Charlson Comorbidity Index, C-reactive protein; nearest neighbor match) to patients without IB (IB-) who also received surgical IE therapy. All IB+ patients underwent a careful risk-benefit analysis before therapy. Results Of 286 consecutive patients (January 2015 - November 2022) operated for left-sided IE, 36 had IB (65±13 years, 26% female): 11 with HT1, 9 with HT2, 8 with PH1, and 8 with PH2. These patients were matched with 36 operated IB- patients. Survival analysis showed no overall effect of IB+ vs. IB- (p = 0.112, 95% CI of hazard ratio was 0.246-1.243 vs. 0.709-3.572). Although there was no effect of IB on survival in the mild IB subgroup (HT1/2, Figure A), there was a difference in patients with severe IB (PH1/2) with less survival in IB+ (Figure B). Neurological outcome (ΔmRS) showed an effect of IB grade in the two-way ANOVA analysis (p = 0.029). Intergroup comparison showed a significantly better outcome for IB- (vs. IB+) in the PH2 subgroup (p = 0.034), but not in other subgroups. For all groups, the mean ΔmRS for IB+ was 1.1±1.6 vs. 0.70±1.4 for IB- (p = 0.256). The mean FU time was 2.6±2.1 years. Conclusion In patients operated for left-sided IE, mild IB did not affect survival or neurological outcome. In the more severe forms of IB, i.e. PH1 and PH2, survival was less favorable compared to matched controls. Furthermore, we observed a difference in neurological outcome in patients with severe IB. Thus, surgical therapy of left-sided IE should be avoided in patients with severe IB, whereas we can add evidence to the safety of surgical therapy in mild IB. Therefore, we recommend regular assessment of the degree of IB in such patients.Figure

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.