Neurological Outcome Research Articles

Fluid excess on intensive care unit after mechanical thrombectomy after acute ischemic stroke is associated with unfavorable neurological and functional outcomes: An observational cohort study.

Endovascular thrombectomy stands as a pivotal component in the standard care for patients experiencing acute ischemic stroke with large vessel occlusion. Subsequent care for patients often extends to a neurological intensive care unit. While fluid management is integral to intensive care, the association between early fluid balance and neurological and functional outcomes post-thrombectomy has not yet been thoroughly investigated. In a retrospective analysis of an observational, single-center study spanning from 2015 to 2021 at the University Medical Center Hamburg-Eppendorf, Germany, we enrolled stroke patients who underwent thrombectomy and received subsequent treatment in the ICU. Unfavorable functional and neurological outcome was defined as a mRS > 2 on day 90 after admission (mRS d90) or NIHSS > 5 at discharge, respectively. A multivariate regression model, adjusting for confounders, utilized the average fluid balance in the first 5 days to predict outcomes. Patients were dichotomized by their average fluid balance (>1 L vs <1 L) within the first 5 days, and a multivariate mRS d90 shift analysis was conducted after adjusting for covariates. Between 2015 and 2021, 1252 patients underwent thrombectomy, and 553 patients met the inclusion criteria (299 women [54%]). Unfavorable functional outcome was significantly associated with a higher daily average fluid balance in the first 5 days in the ICU (mRS d90 ⩽ 2: 0.3 ± 0.5 L, mRS d90 > 2: 0.7 ± 0.7 L, p = 0.02). The same association was observed for the NIHSS at discharge (NIHSS ⩽ 5: 0.3 ± 0.5 L; NIHSS > 5: 0.6 ± 0.6 L; p = 0.03). The mRS d90 shift analysis revealed significance for patients with an average fluid balance <1 L for better functional outcomes (adjusted odds ratio [AOR] 2.17; 95% confidence interval [CI] 1.54-3.07; p < 0.01). Fluid retention in post-thrombectomy stroke patients in the ICU is associated with poorer functional and neurological outcomes. Consequently, fluid retention emerges as an additional potential predictor for post-intervention stroke outcomes. Our findings provide an initial indication that preventing excessive fluid retention in stroke patients after endovascular thrombectomy could be beneficial for both functional and neurological recovery. Therefore, fluid retention might be an element to consider in optimizing fluid management for stroke patients.

Post cardiotomy extracorporeal membrane oxygenation in pediatric patients: Results and neurodevelopmental outcomes.

The increasing complexity of congenital cardiac surgery has led to greater utilization of extracorporeal membrane oxygenation (ECMO) support for children post-surgery. This study aims to identify risk factors for mortality and brain injury in pediatric patients requiring post-cardiotomy ECMO and to evaluate their neurological outcomes. This retrospective study includes pediatric patients with congenital heart diseases who required ECMO after surgery. Risk factors for in-hospital mortality and brain injury were assessed. Neurodevelopmental status was determined using the Pediatric Cerebral Performance Category (PCPC) Scale at discharge and during follow-up. Between October 2014 and May 2021, 2651 pediatric patients underwent cardiac surgery, with 90 (3.4%) requiring ECMO. The mean age was 0.6 years, ranging from 1 day to 13 years and 7 months. ECMO was implemented for 45 patients due to CPB weaning failure (NW-CPB), 24 due to postoperative low-cardiac output syndrome (LCOS), and 21 for extracorporeal cardiopulmonary resuscitation (E-CPR). ECMO weaning was achieved in 73 patients (81%), with an overall mortality rate of 36%. Pre-implant lactate levels (OR: 1.13, 95% CI: 1.03-1.25; p = 0.009) and peak bilirubin levels (OR: 1.04, 95% CI: 0.87-1.24; p = 0.69) were risk factors for in-hospital mortality. Survival rates were 79% for LCOS, 60% for NW-CPB, and 48% for E-CPR. Brain injury incidence was 33%, with E-CPR being a significant risk factor (p = 0.006) and NW-CPB being protective (p = 0.001). Follow-up in November 2023 showed significant improvement in neurodevelopmental status (p < 0.001). Elevated pre-implant lactate and elevated bilirubin levels during ECMO are major risk factors for mortality. E-CPR is the primary risk factor for brain injury. Follow-up revealed significant improvements in neurodevelopmental outcomes.

The association of intravenous vs. humeral-intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AimWhile intravenous (IV) vascular access for out-of-hospital cardiac arrest (OHCA) resuscitation is standard, humeral-intraosseous (IO) access is commonly used, despite few supporting data. We investigated the association between IV vs. humeral-IO and outcomes. MethodsWe utilized BC Cardiac Arrest Registry data, including adult OHCA where the first-attempted intra-arrest vascular access route performed by advanced life support (ALS)-trained paramedics was IV or humeral-IO. We fit a propensity-score adjusted model with inverse probability treatment weighting to estimate the association between IV vs. humeral-IO routes and favorable neurological outcomes (CPC 1–2) and survival at hospital discharge. We repeated models within subgroups defined by initial cardiac rhythm. ResultsWe included 2,112 cases; the first-attempted route was IV (n = 1,575) or humeral-IO (n = 537). Time intervals from ALS-paramedic on-scene arrival to vascular access (6.6 vs. 6.9 min) and epinephrine administration (9.0 vs. 9.3 min) were similar between IV and IO groups, respectively. Among IV and humeral-IO groups, 98 (6.2%) and 20 (3.7%) had favorable neurological outcomes. Compared to humeral-IO, an IV-first approach was associated with improved hospital-discharge favorable neurological outcomes (AOR 1.7; 95% CI 1.1–2.7) and survival (AOR 1.5; 95% CI 1.0–2.3). Among shockable rhythm cases, an IV-first approach was associated with improved favorable neurological outcomes (AOR 4.2; 95% CI 2.1–8.2), but not among non-shockable rhythm cases (AOR 0.73; 95% CI 0.39–1.4). ConclusionAn IV-first approach, compared to humeral-IO, for intra-arrest resuscitation was associated with an improved odds of favorable neurological outcomes and survival to hospital discharge. This association was seen among an initial shockable rhythm, but not non-shockable rhythm, subgroups.

Prognostic value of grey-white matter ratio obtained within two hours after return of spontaneous circulation in out-of-hospital cardiac arrest survivors: A multicenter, observational study

BackgroundGrey-white matter ratio (GWR) measured by head computed tomography (CT) scan is known as a neurological prognostication tool for out-of-hospital cardiac arrest (OHCA) survivors. The prognostic value of GWR obtained early (within two hours after return of spontaneous circulation [ROSC]) remains a matter of debate. MethodsWe conducted a multicenter, retrospective, observational study at five hospitals. We included adult OHCA survivors who underwent head CT within two hours following ROSC. GWR values were measured using head CT. Average GWR values were calculated by the mean of the GWR-basal ganglia and GWR-Cerebrum. We divided the patients into poor or favorable neurological outcome groups defined by Glasgow-Pittsburgh Cerebral Performance Category scores. The predictive accuracy of GWR performance was assessed using the area under the curve (AUC). The sensitivities and specificities for predicting poor outcome were examined. ResultsOf 377 eligible patients, 281 (74.5%) showed poor neurological outcomes at one month after ROSC. Average GWR values of the poor neurological outcome group were significantly lower than those of the favorable neurological outcome. The average GWR value to predict neurological outcome with Youden index was 1.24 with AUC of 0.799. When average GWR values were 1.15 or lower, poor neurological outcomes could be predicted with 100% specificity. ConclusionsGWR values measured by head CT scans early (within two hours after ROSC) demonstrated moderate predictive performance for overall ROSC patients. When limited to the patients with GWR values of 1.15 or lower, poor neurological outcomes could be predicted with high specificity.

Role of surgery in the treatment of pediatric low-grade glioma with various degrees of brain stem involvement

ObjectivePosterior fossa pediatric low-grade glioma involving the brainstem and cerebellar peduncles (BS-pLGG) are a subgroup with higher risks at surgery. We retrospectively analyzed the role of surgery in the interdisciplinary armamentarium of treatment options in our institutional series of BS-pLGG with various degrees of brainstem involvement.Material and methodsWe analyzed data of 52 children with BS-pLGG after surgical intervention for clinical/molecular characteristics, neurological outcome, factors influencing recurrence/progression pattern, and tumor volumetric analysis of exclusively surgically treated patients to calculate tumor growth velocity (TGV). Tumors were stratified according to primary tumor origin in four groups: (1) cerebellar peduncle, (2) 4th ventricle, (3) pons, (4) medulla oblongata.ResultsThe mean FU was 6.44 years. Overall survival was 98%. The mean PFS was 34.07 months. Two patients had biopsies only. Fifty-two percent of patients underwent remission or remained in stable disease (SD) after initial surgery. Patients with progression underwent further 23 resections, 15 chemotherapies, 4 targeted treatments, and 2 proton radiations. TGV decreased after the 2nd surgery compared to TGV after the 1st surgery (p < 0.05). The resection rates were significantly higher in Groups 1 and 2 and lowest in medulla oblongata tumors (Group 4) (p < 0.05). More extended resections were achieved in tumors with KIAA1549::BRAF fusion (p = 0.021), which mostly occurred in favorable locations (Groups 1 and 2). Thirty-one patients showed postoperatively new neurological deficits. A total of 27/31 improved within 12 months. At the end of FU, 6% had moderate deficits, 52% had mild deficits not affecting activities, and 36% had none. Fifty percent of patients were free of disease or showed remission, 38% were in SD, and 10% showed progression.ConclusionThe first surgical intervention in BS-pLGG can control disease alone in overall 50% of cases, with rates differing greatly according to location (Groups 1 > 2 > 3 > 4), with acceptable low morbidity. The second look surgery is warranted except in medullary tumors. With multimodality treatments almost 90% of patients can obtain remission or stable disease after > 5 years of follow-up. An integrated multimodal and multidisciplinary approach aiming at minimal safe residual disease, combining surgery, chemo-, targeted therapy, and, as an exception, radiation therapy, is mandatory.

Utility of Diffusion Tensor Imaging in Preterm Infants with Germinal Matrix Hemorrhage and Intraventricular Hemorrhage: A Systematic Review

IntroductionIntraventricular hemorrhage (IVH) and germinal matrix hemorrhage (GMH) are the most common brain injuries in preterm infants. Neonates with these injuries are at greater risk of impaired neurodevelopmental outcome. Current guidelines recommend screening infants with cranial ultrasound (CUS), although this is prone to missing subtle injury patterns, particularly within the posterior fossa. The present report sought to discuss the utility of diffusion tensor imaging (DTI) in preterm infants. MethodsA systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality; DTI use; neurologic outcome. ResultsTwenty studies with 1574 infants who underwent DTI were included. There were 574 preterm infants with GMH-IVH on DTI. Twelve studies documented decreased fractional anisotropy (FA) while six demonstrated structural segregation and asymmetrical white matter myelination in these infants. Seven studies documented concurrent CUS use with two studies comparing DTI findings to CUS findings. In both studies, DTI more accurately detected presence of GMH, especially within the cerebellum. Among GMH-IVH preterm infants, 58.5% demonstrated cognitive, intellectual, and language delays at follow-up (mean: 32.4 months). Additionally, lower FA values on initial DTI were associated with cognitive, language, and motor delays. ConclusionAlthough DTI is more sensitive for picking up subtle injury patterns, CUS remains the standard of care when screening for injuries that would necessitate surgical intervention. DTI offers a refined understanding of the sequelae of GMH-IVH with microstructural changes found on DTI being associated with childhood motor and cognitive outcomes.

Performance of the ERC/ESICM-recommendations for neuroprognostication after cardiac arrest: Insights from a prospective multicenter cohort

AimTo investigate the performance of the 2021 ERC/ESICM-recommended algorithm for predicting poor outcome after cardiac arrest (CA) and potential tools for predicting neurological recovery in patients with indeterminate outcome. MethodsProspective, multicenter study on out-of-hospital CA survivors from 28 ICUs of the AfterROSC network. In patients comatose with a Glasgow Coma Scale motor score ≤3 at ≥72 h after resuscitation, we measured: (1) the accuracy of neurological examination, biomarkers (neuron-specific enolase, NSE), electrophysiology (EEG and SSEP) and neuroimaging (brain CT and MRI) for predicting poor outcome (modified Rankin scale score ≥4 at 90 days), and (2) the ability of low or decreasing NSE levels and benign EEG to predict good outcome in patients whose prognosis remained indeterminate. ResultsAmong 337 included patients, the ERC-ESICM algorithm predicted poor neurological outcome in 175 patients, and the positive predictive value for an unfavourable outcome was 100% [98–100]%. The specificity of individual predictors ranged from 90% for EEG to 100% for clinical examination and SSEP. Among the remaining 162 patients with indeterminate outcome, a combination of 2 favourable signs predicted good outcome with 99[96–100]% specificity and 23[11–38]% sensitivity. ConclusionAll comatose resuscitated patients who fulfilled the ERC-ESICM criteria for poor outcome after CA had poor outcome at three months, even if a self-fulfilling prophecy cannot be completely excluded. In patients with indeterminate outcome (half of the population), favourable signs predicted neurological recovery, reducing prognostic uncertainty.

Impact of inhaled sedation on delirium incidence and neurological outcome after cardiac arrest – A propensity-matched control study (Isocare)

RationalePoor neurological outcome is common following a cardiac arrest. The use of volatile anesthetic agents has been proposed during post-resuscitation to improve outcome. ObjectivesTo determine the effects of inhaled isoflurane on neurological outcome, delirium incidence, ICU length-of-stay, ventilation duration, mortality during post-resuscitation care of ICU patients. Patients510 patients were admitted within our medical ICU following a cardiac arrest during the study period, 401 of them being sedated using intravenous sedation prior to 2017 and 109 of them using inhaled isoflurane according to a standardized protocol following 2017. ResultsMatched-pair analysis depicted a delirium incidence decrease, without improved neurologic outcome on ICU discharge (CPC ≤ 2) for isoflurane patients (16.1% vs 32.2%, p 0.03 and 29% vs 23%, p 0.47, respectively). Ventilation duration and ICU length of stay were shorter for isoflurane patients (78 vs 167 h, p 0.01 and 7.9 vs 8.5 days, p 0.01 respectively). Isoflurane had no impact on mortality. ConclusionIn this propensity-matched control study, isoflurane sedation during the post-resuscitation care of ICU patients was associated with a lower incidence of delirium, a shorter duration of mechanical ventilation and a reduced ICU length of stay. Prospective data are needed before its widespread use.

Early Maintenance Treatment Initiation and Relapse Risk Mitigation After a First Event of MOGAD in Adults: The MOGADOR2 Study.

Because myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a recently identified autoimmune disorder, the natural history of MOGAD is still not well described. The objective of this study was to describe the long-term outcomes of adult patients with MOGAD. In addition, we aimed to identify factors affecting relapse risk and neurologic outcomes. Clinical and biological data were obtained from patients with a first event of MOGAD and included in the French nationwide incident cohort between February 2014 and March 2017. Only patients aged 18 years or older at disease onset and with observation period of at least 3 months were included. Data were collected prospectively until July 2023 and registered in the dedicated French nationwide database. This form includes every relapse with phenotype description during follow-up, date of last assessment, final clinical outcome with Expanded Disability Status Scale score and visual acuity, and maintenance therapy. The probability of recurrence-free survival was assessed using the Kaplan-Meier method. We included 128 patients. The onset phenotype was isolated optic neuritis in 81 patients (63.3%) and isolated myelitis in 25 patients (19.5%). The median follow-up duration was 77.8 months (range 3.2-111.2), with 49 patients (38.3%) experienced at least one relapse. Median times from onset to second and third attacks were 3.2 (1.0-86.2) and 13.0 (2.6-64.4) months, respectively. At the last assessment, Expanded Disability Status Scale Score was ≥3 and ≥6 in 22 (17.2%) and 6 (4.7%) patients, respectively. Eighty patients received at least one maintenance treatment. This treatment was initiated after the first attack in 47 patients (36.7% of the whole cohort) and at the time of a second attack in 25 (19.5%). Multivariate analysis revealed that initiating maintenance treatment after the first attack was associated with a lower relapse risk (OR = 0.26 [95% CI 0.11-0.62], p = 0.002). In patients receiving maintenance therapy after first attack, the 2-year, 4-year, 6-year, and 8-year relapse risks were 11%, 15%, 20%, and 20%, respectively. In other patients, the risks were 41%, 46%, 51%, and 56%. The highest risk of a relapse in MOGAD occurs early, and initiating maintenance therapy from the first attack substantially reduced the relapse risk. This study provides Class III evidence that initiating maintenance therapy from the first attack in patients with MOGAD reduces the relapse risk.

Simultaneous prognostic score validation in patients with out-of-hospital cardiac arrest by a post-hoc analysis based on national multicenter registry

Using a nationwide multicenter prospective registry in Japan’s data, we calculated prognostic and predictive scores, including the Out-of-Hospital Cardiac Arrest (OHCA); Cardiac Arrest Hospital Prognosis (CAHP); Nonshockable rhythm, Unwitnessed arrest, Long no-flow or Long low-flow period, blood PH < 7.2, Lactate > 7.0 mmol/L, End-stage chronic kidney disease on dialysis, Age ≥ 85 years, Still resuscitation, and Extracardiac cause (NULL-PLEASE); revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST); and MIRACLE2 scores, for adult patients with cardiac arrest. The MIRACLE2 score was validated with the modified MIRACLE2 score, which excludes information of pupillary reflexes. Each score was calculated only for the cases with no missing data for the variables used. These scores’ accuracies were compared using neurological outcomes 30 days after out-of-hospital cardiac arrest (OOHCA). Patients with a cerebral performance category scale of 1 or 2 were designated as having favorable neurological outcomes. Each score’s discrimination ability was evaluated by the receiver operating characteristic curve’s area under the curve (AUC). To assess in detail in areas of high specificity and high sensitivity, which are areas of interest to clinicians, partial AUCs were also used. The analysis included 11,924 hospitalized adult patients. The AUCs of the OHCA, MIRACLE2, CAHP, rCAST, and NULL-PLEASE scores for favorable neurological outcomes were 0.713, 0.727, 0.785, 0.761, and 0.831, respectively. The CAHP and NULL-PLEASE scores were significantly more accurate than the rest. Accuracies did not differ significantly between the CAHP and NULL-PLEASE scores. The NULL-PLEASE score was significantly better at discriminating favorable neurological prognoses at 30 days in patients with OOHCA compared to other scoring systems.

Middle meningeal artery embolization following surgical evacuation of symptomatic chronic subdural hematoma improves outcomes, interim results of a prospective randomized trial

BackgroundOutcomes after surgical treatment of chronic subdural hematoma (cSDH) remain undesirable in a significant proportion of patients. We aimed to show the role of middle meningeal artery (MMA) embolization and to demonstrate its benefits. MethodsThirty-five patients with symptomatic cSDH were enrolled in a prospective randomized trial following evacuation surgery. Participants were randomized to embolization or control group (expectant management following surgical evacuation without embolization). Patients were followed throughout their hospitalization and outpatient follow-ups. The main goals of this planned interim analysis were to assess neurological outcome and resource utilization. ResultsThe groups were comparable in terms of sex, age and follow-up retention rates. Side(s) of intervention(s) and hematoma size were similar. There was no statistical difference in neurological examination improvement at discharge, but at follow-up, we observed a decline in neurologic exam in the control group (p = 0.03). Control group participants required more re-interventions (p = 0.02) and were followed in clinic and during related readmissions for longer (p = 0.02). The number of imaging studies obtained in relation to the disease management was higher in the control group (p = 0.01). ConclusionsOur results suggest a beneficial role for the addition of MMA embolization to surgical intervention in the treatment of symptomatic chronic subdural hematoma. Neurological outcomes were significantly better in the embolization group. This contributed to less need for follow-up, re-interventions, and imaging studies.

Quantitative Characterization of Rhythmic and Periodic EEG Patterns in Patients in a Coma After Cardiac Arrest and Association With Outcome.

Rhythmic and periodic patterns (RPPs) on EEG in patients in a coma after cardiac arrest are associated with a poor neurologic outcome. We characterize RPPs using qEEG in relation to outcomes. Post hoc analysis was conducted on 172 patients in a coma after cardiac arrest from the TELSTAR trial, all with RPPs. Quantitative EEG included corrected background continuity index (BCI*), relative discharge power (RDP), discharge frequency, and shape similarity. Neurologic outcomes at 3 months after arrest were categorized as poor (CPC = 3-5) or good (CPC = 1-2). A total of 16 patients (9.3%) had a good outcome. Patients with good outcomes showed later RPP onset (28.5 vs 20.1 hours after arrest, p < 0.05) and higher background continuity at RPP onset (BCI* = 0.83 vs BCI* = 0.59, p < 0.05). BCI* <0.45 at RPP onset, maximum BCI* <0.76, RDP >0.47, or shape similarity >0.75 were consistently associated with poor outcomes, identifying 36%, 22%, 40%, or 24% of patients with poor outcomes, respectively. In patients meeting both BCI* >0.44 at RPP onset and BCI* >0.75 within 72 hours, the probability of good outcomes doubled to 18%. Sufficient EEG background continuity before and during RPPs is crucial for meaningful recovery. Background continuity, discharge power, and shape similarity can help select patients with relevant chances of recovery and may guide treatment. February 4, 2014, ClinicalTrial.gov, NCT02056236.

Activation of GPR30 Ameliorates Cerebral Ischemia-Reperfusion Injury by Suppressing Ferroptosis Through Nrf2/GPX4 Signaling Pathway.

The newly identified estrogen receptor, G protein-coupled receptor 30 (GPR30), is prevalent in the brain and has been shown to provide significant neuroprotection. Recent studies have linked ferroptosis, a newly characterized form of programmed cell death, closely with cerebral ischemia-reperfusion injury (CIRI), highlighting it as a major contributing factor. Consequently, our research aimed to explore the potential of GPR30 targeting in controlling neuronal ferroptosis and lessening CIRI impacts. Results indicated that GPR30 activation not only improved neurological outcomes and decreased infarct size in a mouse model but also lessened iron accumulation and malondialdehyde formation post-middle cerebral artery occlusion (MCAO). This protective effect extended to increased levels of Nrf2 and GPX4 proteins. Similar protective results were replicated in PC12 cells subjected to Oxygen Glucose Deprivation and Reoxygenation (OGD/R) using the GPR30-specific agonist G1. Importantly, inhibition of Nrf2 with ML385 curtailed the neuroprotective effects of GPR30 activation, suggesting that GPR30 mitigates CIRI primarily through inhibition of neuronal ferroptosis via upregulation of Nrf2 and GPX4.

Anatomical and Radiological Findings of Abnormal Calcified Structures within and around the Foramen Transversarium and Its Clinical Implications.

The foramen transversarium is a vital anatomical structure found in the cervical vertebrae of the spine. Typically, it serves as a passageway for important neurovascular structures, including the vertebral artery and vein, as well as the vertebral nerve. However, abnormal calcification or ossification of soft tissues in and around this area can lead to various clinical implications. Understanding the presence and implications of abnormal ossified structures in and around the foramen transversarium is crucial for clinicians involved in the diagnosis and management of cervical spine disorders. Accordingly, this present study was designed to evaluate the abnormal ossified structures anatomically and radiologically within and around the foramen transversarium. This study was conducted on 182 (26 sets of cervical vertebrae) dried human cervical vertebrae obtained from the respective departments of anatomy and on 190 (95 males and 95 females) adult patients who visited the radiology department for neck-related problems such as stiff neck, neck/shoulder pain, dizziness, vertigo, imbalance, visual disturbances, and cognitive impairment. Among 182 examined cervical vertebrae, unilateral complete accessory foramen transversarium was found in 23 vertebrae (12.63%), bilateral complete in 19 (10.44%), bilateral incomplete in 6 (3.29%), unilateral complete double in 4 (2.19%), and unilateral complete absence of foramen transversarium in 3 (1.64%). Stenosis due to aberrant osteophytes was noted in 9 vertebrae (4.9%). Out of 190 patients, three males presented with cervical kyphosis, severe spinal canal stenosis, and spinal cord compression due to ossification of the posterior longitudinal ligament and osteophyte complexes at C3-C6, with the most significant compression at C5-C6. A thorough understanding of abnormal ossifications in and around the foramen transversarium is crucial for the management of cervical spine disorders; imaging modalities such as X-ray, computed tomography, and magnetic resonance imaging are crucial for recognizing and intervening in these cases, which is essential to prevent adverse neurological outcomes associated with vertebral artery involvement.

Combination of Hydrogen Inhalation and Hypothermic Temperature Control After Out-of-Hospital Cardiac Arrest: A Post hoc Analysis of the Efficacy of Inhaled Hydrogen on Neurologic Outcome Following Brain Ischemia During PostCardiac Arrest Care II Trial.

The Efficacy of Inhaled Hydrogen on Neurologic Outcome Following Brain Ischemia During Post-Cardiac Arrest Care (HYBRID) II trial (jRCTs031180352) suggested that hydrogen inhalation may reduce post-cardiac arrest brain injury (PCABI). However, the combination of hypothermic target temperature management (TTM) and hydrogen inhalation on outcomes is unclear. The aim of this study was to investigate the combined effect of hydrogen inhalation and hypothermic TTM on outcomes after out-of-hospital cardiac arrest (OHCA). Post hoc analysis of a multicenter, randomized, controlled trial. Fifteen Japanese ICUs. Cardiogenic OHCA enrolled in the HYBRID II trial. Hydrogen mixed oxygen (hydrogen group) versus oxygen alone (control group). TTM was performed at a target temperature of 32-34°C (TTM32-TTM34) or 35-36°C (TTM35-TTM36) per the institutional protocol. The association between hydrogen + TTM32-TTM34 and 90-day good neurologic outcomes was analyzed using generalized estimating equations. The 90-day survival was compared between the hydrogen and control groups under TTM32-TTM34 and TTM35-TTM36, respectively. The analysis included 72 patients (hydrogen [ n = 39] and control [ n = 33] groups) with outcome data. TTM32-TTM34 was implemented in 25 (64%) and 24 (73%) patients in the hydrogen and control groups, respectively ( p = 0.46). Under TTM32-TTM34, 17 (68%) and 9 (38%) patients achieved good neurologic outcomes in the hydrogen and control groups, respectively (relative risk: 1.81 [95% CI, 1.05-3.66], p < 0.05). Hydrogen + TTM32-TTM34 was independently associated with good neurologic outcomes (adjusted odds ratio 16.10 [95% CI, 1.88-138.17], p = 0.01). However, hydrogen + TTM32-TTM34 did not improve survival compared with TTM32-TTM34 alone (adjusted hazard ratio: 0.22 [95% CI, 0.05-1.06], p = 0.06). Hydrogen + TTM32-TTM34 was associated with improved neurologic outcomes after cardiogenic OHCA compared with TTM32-TTM34 monotherapy. Hydrogen inhalation is a promising treatment option for reducing PCABI when combined with TTM32-TTM34.

Prediction of neurologic outcome after out-of-hospital cardiac arrest: An interpretable approach with machine learning

Out-of-hospital cardiac arrest (OHCA) is a critical condition with low survival rates. In patients with a return of spontaneous circulation, brain injury is a leading cause of death.In this study, we propose an interpretable machine learning approach for predicting neurologic outcome after OHCA, using information available at the time of hospital admission. MethodsThe study population were 55 615 OHCA cases registered in the Swedish Cardiopulmonary Resuscitation Registry between 2010 and 2020. The dataset was split to training and validation sets (for model development) and test set (for evaluation of the final model). We used an XGBoost algorithm with stratified, repeated 10-fold cross-validation along with Optuna framework for hyperparameters tuning. The final model was trained on 10 features selected based on the importance scores and evaluated on the test set in terms of discrimination, calibration and bias-variance tradeoff. We used SHapley Additive exPlanations to address the ‘black-box’ model and align with eXplainable artificial intelligence. ResultsThe final model achieved: area under the receiver operating characteristic value 0.964 (95% confidence interval (CI) [0.960–0.968]), sensitivity 0.606 (95% CI [0.573–0.634]), specificity 0.975 (95% CI [0.972–0.978]), positive predictive value (PPV) 0.664 (95% CI [0.625–0.696]), negative predictive value (NPV) 0.969 (95% CI [0.966–0.972]), macro F1 0.803 (95% CI [0.788–0.816]), and showed a very good calibration. SHAP features with the highest impact on the model’s output were:’ROSC on arrival to hospital’, ‘Initial rhythm asystole’ and ‘Conscious on arrival to hospital’. ConclusionsThe XGBoost machine learning model with 10 features available at the time of hospital admission showed good performance for predicting neurologic outcome after OHCA, with no apparent signs of overfitting.

Impact of extracorporeal cardiopulmonary resuscitation on neurological prognosis and survival in adult patients after cardiac arrest: An individual pooled patient data meta-analysis

BackgroundWe aimed to estimate the effect of extracorporeal cardiopulmonary resuscitation (ECPR) on neurological outcome and mortality, when compared to conventional cardiopulmonary resuscitation (CCPR), using an individual patient data meta-analysis (IPDMA). MethodsA systematic literature search was performed up to the 20th of October 2022 in the PubMed, EMBASE and CENTRAL databases. For observational studies with unmatched populations, a propensity score including age, location of arrest and initial rhythm was used to match ECPR and CCPR patients in a 1:1 ratio. The primary and secondary outcomes were unfavorable neurological outcome (Cerebral Performance Category of 3–5) and mortality, respectively, which were both collected at different time-points. ResultsData from 17 studies, including 2064 matched cardiac arrest (CA) patients (1031 ECPR and 1033 CCPR cases) were included. In comparison to CCPR, ECPR was associated with a decreased odds of unfavorable neurological outcome (847, 82.2% vs. 897, 86.8% − OR 0.68 [95%CI 0.53–0.87]; p = 0.002) and death (803, 77.9% vs. 860, 83.3% − OR 0.68 [95%CI 0.54–0.86]; p = 0.001). These results were consistent across most of the prespecified subgroups. Moreover, the odds of both unfavorable neurological outcome and mortality were significantly influenced by initial rhythm, cause of arrest and combinations of lactate levels on admission and duration of resuscitation. ConclusionsThis IPDMA showed that ECPR was associated with significantly lower rates of unfavorable neurological outcome and mortality in refractory CA. The overall effect could be influenced by CA characteristics and the severity of the initial injury.

Exploring the potential of routine serological markers in predicting neurological outcomes in spinal cord injury

Spinal cord injury (SCI) is a rare condition with a heterogeneous presentation, making the prediction of recovery challenging. However, serological markers have been shown to be associated with severity and long-term recovery following SCI. Therefore, our investigation aimed to assess the feasibility of translating this association into a prediction of the lower extremity motor scores (LEMS) at chronic stage (52 weeks after initial injury) in patients with SCI using routine serological markers.Serological markers, assessed within the initial seven days post-injury in the observational cohort study from the Trauma Hospital Murnau underwent diverse feature engineering approaches. These involved arithmetic measurements such as mean, median, minimum, maximum, and range, as well as considerations of the frequency of marker testing and whether values fell within the normal range. To predict LEMS scores at the chronic stage, eight different regression models (including linear, tree-based, and ensemble models) were used to quantify the predictive value of serological markers relative to a baseline model that relied on the very acute LEMS score and patient age alone.The inclusion of serological markers did not improve the performance of the prediction model. The best-performing approach including serological markers achieved a mean absolute error (MAE) of 6.59 (2.14), which was equivalent to the performance of the baseline model. As an alternative approach, we trained separate models based on the LEMS observed at the very acute stage after injury. Specifically, we considered individuals with an LEMS of 0 or an LEMS exceeding zero separately. This strategy led to a mean improvement in MAE across all cohorts and models, of 1.20 (2.13).We conclude that, in our study, routine serological markers hold limited power for prediction of LEMS. However, the implementation of model stratification by the very acute LEMS markedly enhanced prediction performance. This observation supports the inclusion of clinical knowledge in the modeling of prediction tasks for SCI recovery. Additionally, it lays the path for future research to consider stratified analyses when investigating the predictive power of potential biomarkers.

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.

Unfavorable neurological long-term outcome despite eTICI 3 – What are the predictors?

PurposeInterventional stroke therapy has become standard treatment for patients with acute ischemic strokes. Complete reperfusion (eTICI 3) portrays the best possible technical outcome. The purpose of this study was to determine possible predictors for an unfavorable neurological long-term outcome (mRS 3–6) despite achieving the best possible treatment success. MethodsWe evaluated 122 patients with stroke in the anterior circulation and complete reperfusion after mechanical thrombectomy (MT) between May 2010 and March 2020. We performed a binary logistic regression analysis with patient baseline data, stroke severity, comorbidities, premedication and treatment information as independent variables. Results50 of the 122 patients included in our study showed a poor clinical outcome after 90 days (41 %). Multivariable logistic regression analysis showed that older age (p = 0.033), higher admission NIHSS (p=0.009), lower admission ASPECTS (p=0.005), a pre-existing cardiovascular disease (p=0.017), and multiple passes for complete reperfusion (p=0.030) had an independent impact on unfavorable outcome. ConclusionsOlder age, higher NIHSS upon admission, lower ASPECTS upon admission, cardiovascular comorbidities and multiple passes for complete reperfusion are predictors for poor neurological long-term outcome despite complete reperfusion.