Coma Outcome Research Articles

Clinical Features and Outcomes of Myxedema Coma in Patients Hospitalized for Hypothyroidism: Analysis of the United States National Inpatient Sample.

Background: Hypothyroidism is a common endocrine condition and chronic thyroid hormone deficiency is associated with adverse effects across multiple organ systems. In compensated hypothyroidism, however, patients remain clinically stable due to gradual physiological adaptation. In contrast, the clinical syndrome of decompensated hypothyroidism referred to as myxedema coma (MC) is an endocrine emergency with high risk of mortality. Because of its rarity, there are currently limited data regarding MC. This study analyzes the clinical features and hospital outcomes of MC compared with hypothyroid patients without MC (nonMChypo) in national United States hospital data. Methods: A retrospective analysis of the National Inpatient Sample, a public database of inpatient admissions to nonfederal hospitals in the United States, 2016-2018, including adult patients with primary diagnosis of MC (International Classification of Diseases 10th Revision [ICD-10]: E03.5) or nonMChypo (E03.0-E03.9, E89.0). Patient demographics, relevant clinical features, mortality, length of stay (LOS), and hospital costs were compared. Results: Of 18,635 patients hospitalized for hypothyroidism, 2495 (13.4%) had a diagnosis of MC. Sex distribution and race/ethnicity were similar between patients with MC and nonMChypo, whereas MC was associated with older patient age (p = 0.02), public insurance (p = 0.01), and unhoused status (p = 0.04). More admissions with MC occurred in winter compared with other seasons (p = 0.01). The overall mortality rate for MC was 6.8% versus 0.7% for nonMChypo (p < 0.001), and MC was independently associated with in-hospital mortality after adjusted regression analysis (adjusted odds ratio = 9.92 [CI 5.69-17.28], p < 0.001). Mean LOS ± standard error was 9.64 ± 0.73 days for MC versus 4.62 ± 0.12 days for nonMChypo (p < 0.001), and total hospital cost for MC was $21,768 ± $1759 versus $8941 ± $276 for nonMChypo (p = 0.07). In linear regression analyses, MC was an independent predictor of both increased LOS and total hospital cost. Conclusions: In summary, MC remains a clinically significant diagnosis in the modern era, independently associated with high mortality and health care costs. This continued burden demonstrates a need for further efforts to prevent, identify, and optimize treatment for patients with MC.

Neuroimmune activation is associated with neurological outcome in anoxic and traumatic coma.

The pathophysiological underpinnings of critically disrupted brain connectomes resulting in coma are poorly understood. Inflammation is potentially an important but still undervalued factor. Here, we present a first-in-human prospective study using the 18-kDa translocator protein (TSPO) radioligand 18F-DPA714 for PET imaging to allow in vivo neuroimmune activation quantification in patients with coma (n = 17) following either anoxia or traumatic brain injuries in comparison with age- and sex-matched controls. Our findings yielded novel evidence of an early inflammatory component predominantly located within key cortical and subcortical brain structures that are putatively implicated in consciousness emergence and maintenance after severe brain injury (i.e. mesocircuit and frontoparietal networks). We observed that traumatic and anoxic patients with coma have distinct neuroimmune activation profiles, both in terms of intensity and spatial distribution. Finally, we demonstrated that both the total amount and specific distribution of PET-measurable neuroinflammation within the brain mesocircuit were associated with the patient's recovery potential. We suggest that our results can be developed for use both as a new neuroprognostication tool and as a promising biometric to guide future clinical trials targeting glial activity very early after severe brain injury.

Mortality And Prognostic Factors In Patients Operated For Acute Epidural Hematoma.

Epidural hematoma is one of the most common surgical emergencies encountered in neurosurgery. This study was conducted to determine the mortality and prognostic factors in patients operated for traumatic intracranial epidural hematoma in a resource-constrained setting from a developing country. This retrospective study was conducted in the Department of Neurosurgery at Ayub Teaching Hospital Abbottabad from 1st January 2019 to 31st Dec 2021. Inclusion and exclusion criteria were created. The medical record of 116 patients admitted and operated on for traumatic extradural hematoma was retrospectively reviewed. Information was recorded using a standardized structured questionnaire. The outcome was measured in terms of the Glasgow coma outcome score. Out of 116 patients, 93 were male and 23 were female.19 (16.4%) patients were in the age range 0-5 years, 42 (36.2%) were in the age range 6-15, 35(31.0%) were in the age range 16-30, 11 (9.5%) were in the age range 31-45 years, 7 (6.0%) were in the age range 46-60 years while only one patient included in this study was above 60 years. Overall mortality was 4.3%. Mortality was higher in females and in those aged less than 5 years (3.4%). 4 out of 16 patients died with GCS less than 8, while none of the patients died when GCS was above 12. Mortality was significantly higher in the presence of associated lesions (4.4% vs. 0%) and anisocoria (2.6% vs.1.7%). Patients who operated within 6 hours of trauma resulted in better outcomes with a mortality rate of 0.0% and functional recovery of 57.8 % while for those who operated after 6 hours, mortality was significantly higher (4.3%) and functional recovery was significantly low (15.5%). Good surgical outcomes can be achieved with early operative intervention if indicated. Female gender, low preoperative GCS score, presence of pupillary dilatation, presence of associated lesions, delayed surgical intervention and age less than 5 years are significant predictors for poor outcomes.

Outcome of non-traumatic coma in adults: A 3-year review in a Cameroonian referral hospital

Outcome of non-traumatic coma in adults: A 3-year review in a Cameroonian referral hospital

Comparison of Continuous Sedatives in the Burn ICU on Delirium and Coma.

Lighter sedation targets over the past decade have resulted in improved outcomes for critically ill populations. Although guidelines exist for the general ICU population, these recommendations often exclude the burn population. The purpose of this study is to assess the impact of the initial continuous sedative on coma- and delirium-free days in critically ill patients with burns. This retrospective cohort study evaluated adult patients admitted to a burn intensive care unit at an academic medical center between January 2010 and September 2019. Patients were enrolled into 3 groups based on the depth of initial continuous sedation received (deep, light, or analgosedation). Intubated patients were randomly assessed for inclusion from the National V6 Burn Registry. Patients were included if they received a continuous sedative infusion for at least 48 h. A total of 107 patients were included in the study with 36, 41, and 30 patients receiving deep, light, and analgosedation, respectively. The primary outcome of coma- and delirium-free days was significantly different between sedation types with the most days free in analgosedation and the fewest in deep sedation (8 versus 3 days; P = 0.024). The composite primary outcome was divided into secondary outcomes of coma-free days and delirium-free days, with coma-free days being different (P = 0.00008). Other secondary outcomes of length of stay in the intensive care unit and hospital, time on mechanical ventilation, and survival to discharge were not statistically significant; however, a trend toward higher mortality in deep sedation was noted.

Comprehensive Assessment of Mid-Regional Proadrenomedullin, Procalcitonin, Neuron-Specific Enolase and Protein S100 for Predicting Pediatric Severe Trauma Outcomes.

The development of multiple organ failure and septic complications increases the cumulative risk of mortality in children with severe injury. Clinically available biochemical markers have shown promise in assessing the severity and predicting the development of complications and outcomes in such cases. This study aimed to determine informative criteria for assessing the severity and outcome prediction of severe injury in children based on levels of mid-regional proadrenomedullin (MR-proADM) procalcitonin (PCT), neuron-specific enolase (NSE), and protein S100. Biomarker levels were measured in 52 children with severe injury (ISS ≥ 16) on the 1st, 3rd, 7th, and 14th days after admission to the ICU. The children were divided into groups based on their favorable (n = 44) or unfavorable (n = 8) outcomes according to the Severe Injury Outcome Scale, as well as their favorable (n = 35) or unfavorable (n = 15) outcomes according to the Glasgow Coma Outcome Scale (GOS). The study also evaluated the significance of biomarker levels in predicting septic complications (with SC (n = 16) and without SC (n = 36)) and diagnosing and stratifying multiple organ failure (with MOF (n = 8) and without MOF (n = 44)). A comprehensive assessment of MR-proADM and PCT provided the highest diagnostic and prognostic efficacy for early diagnosis, risk stratification of multiple organ failure, and outcome prediction in severe injury cases involving children. Additionally, the inclusion of the S100 protein in the study allowed for further assessment of brain damage in cases of traumatic brain injury (TBI), contributing to the overall prognostic model.

The effect of sedation and time after cardiac arrest on coma outcome prognostication based on EEG power spectra.

Early prognostication of long-term outcome of comatose patients after cardiac arrest remains challenging. Electroencephalography-based power spectra after cardiac arrest have been shown to help with the identification of patients with favourable outcome during the first day of coma. Here, we aim at comparing the power spectra prognostic value during the first and second day after coma onset following cardiac arrest and to investigate the impact of sedation on prognostication. In this cohort observational study, we included comatose patients (N = 91) after cardiac arrest for whom resting-state electroencephalography was collected on the first and second day after cardiac arrest in four Swiss hospitals. We evaluated whether the average power spectra values at 4.6-15.2 Hz were predictive of patients' outcome based on the best cerebral performance category score at 3 months, with scores ranging from 1 to 5 and dichotomized as favourable (1-2) and unfavourable (3-5). We assessed the effect of sedation and its interaction with the electroencephalography-based power spectra on patient outcome prediction through a generalized linear mixed model. Power spectra values provided 100% positive predictive value (95% confidence intervals: 0.81-1.00) on the first day of coma, with correctly predicted 18 out of 45 favourable outcome patients. On the second day, power spectra values were not predictive of patients' outcome (positive predictive value: 0.46, 95% confidence intervals: 0.19-0.75). On the first day, we did not find evidence of any significant contribution of sedative infusion rates to the patient outcome prediction (P > 0.05). Comatose patients' outcome prediction based on electroencephalographic power spectra is higher on the first compared with the second day after cardiac arrest. Sedation does not appear to impact patient outcome prediction.

Outcomes and Their Predictors in Post- Intensive Care Patients Admitted With Traumatic Brain Injury at Mbarara Regional Referral Hospital, Southwestern Uganda: A Retrospective Study

Purpose: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality worldwide. TBIs are increasing in Uganda, but little is known about outcomes and their predictors in post-ICU patients. This study assessed outcomes and their predictors in post-ICU patients admitted with TBI at Mbarara Regional Referral Hospital (MRRH) in south-western Uganda.&#x0D; Methodology: Retrospective study was used to review hospital records of patients admitted to the Intensive Care Unit (ICU) for MRRH with TBI. Data were entered into Excel, cleaned and exported to Stata version for analysis and presented as mean (standard deviation), median (interquartile range) and number (percent), while using the chi-square test and multinomial logistic regression as predictors for Post-ICU outcomes were used&#x0D; Findings: In the study, males dominated at 73%, while 81% were of working age (15-64 years). Road traffic accidents (83%) were the most common injury mechanism, followed by physical injury at 11%. Length of stay in the Intensive Care Unit was 9 (IQR = 4–8) days, mean GCS at ICU admission and discharge was 7.7 (±2.65) and 10 (±3.27), respectively. Fifty-seven patients (63%) were discharged home; with 73% good recovery Glasgow coma Outcome Scale of hospital discharges. Post-ICU outcomes were associated with GCS at ICU discharge ( . Having moderate Glasgow Coma Scale on ICU discharge was 3.59 times higher of being discharged home than dying compared to severe GCS on ICU discharge (OR=3.59; 95%CI, 1.11 to 11.63). This study established GCS as a statistical predictor of patient outcomes at ICU discharge.&#x0D; Unique Contribution to Theory, Practice and Policy: Based on the findings of this study, prevention of TBI is critical in order to reduce incidence of TBI related mortality. Policy makers to put rules that continuously teach and enforce road safety and traffic rules to all road users.

Comparative analysis between GCS (Glasgow coma scale) and FOUR (Full Outline of Unresponsiveness) score in preliminary assessment and prognostication of traumatic brain injury

Introduction: Head injury is one of the most critical conditions and has a serious neurological outcome if not treated promptly. Effective initial assessment and timely intervention ensures a favourable outcome. To achieve this, many assessment scoring systems have been devised over the years of which Glasgow coma scale (GCS) is the most widely used but it does have a few drawbacks. A newer coma scale, the FOUR score (Full Outline of UnResponsiveness) evaluates four components. The aim of the present study is to compare the GCS and FOUR score in traumatic head injury patients in predicting the better outcome. The outcome scoring is done by GCOS (Glasgow Coma Outcome Scale). Methods and Materials: One twenty-five patients with traumatic head injury were recruited between September 2019 to September 2021 in a tertiary health care centre. For all these cases, GCS and FOUR score on the day of arrival in emergency department (ED) was calculated by residents attending the case in ED and the outcome was scored using GCOS. The correlation between all three scores was then calculated. Results: The present study revealed the major cause of traumatic head injury as road traffic accidents and most of them being males. A significant strong positive correlation was found in FOUR score when compared with GCS in the prediction of outcome in traumatic brain injury patients. Conclusion: It was concluded that the FOUR score is more beneficial to that of GCS and can be used in outcome assessment in traumatic head injury and intubated patients. Thus, FOUR score is a better tool for prognostication.

Relevance of age and hypertension for blood pressure targets in comatose survivors of cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Novo Nordisk Foundation. Background Baseline arterial blood pressure (BP) is influenced by age. Therefore, age and previous hypertension may alter the appropriate BP target after out-of-hospital cardiac arrest (OHCA). Purpose To examine whether the optimal BP target after OHCA is affected by age and a history of arterial hypertension. Methods The Blood Pressure and Oxygenation Targets in Post Resuscitation Care (BOX) trial was a randomized, controlled, double-blind trial comprising 789 comatose patients ≥18 years of age, resuscitated after OHCA of presumed cardiac cause. Patients were randomized to a mean arterial BP target of either 63 mm Hg (low BP target group) or 77 mm Hg (high BP target group). The primary outcome was a composite of death from any cause or hospital discharge with severe cerebral disability within one year. The relationship between age or prevalent hypertension and clinical outcomes was evaluated using Cox proportional-hazards regression. Age was stratified into quartiles. We further determined if the effects of BP target varied across the age spectrum (and according to prevalent hypertension). Results Three-hundred and ninety-three patients were assigned to the high BP target group and 396 to the low BP target group. In all, 204 (25.9%), 201 (25.5%), 186 (23.6%), and 198 (25.1%) were ≤54, 55-64, 65-72, and ≥73 years. Mean age was similar between the two study groups (high BP target 63 ± 13 years versus low BP target 62 ± 14 years; P = 0.60). A total of 176 (45%) patients in the high BP target group and 186 (47%) patients in the low BP target group had known hypertension. At 90 days, 133 patients (34%) in the high BP target group and 127 patients (32%) in the low BP target group had experienced the primary outcome. The risk of the primary outcome increased with higher age (Figure 1). Hazard ratios of the primary outcome according to BP targets within each age quartile (with low BP target as reference) were as follows: ≤54: 1.71; 95% confidence interval [CI], 0.99 to 2.95; P = 0.054, 55-64: 0.92; 95% CI, 0.57 to 1.49; P = 0.73, 65-72: 1.12; 95% CI, 0.73 to 1.74; P = 0.59 and ≥73: 0.88; 95% CI, 0.60 to 1.27; P = 0.48 (Figure 2). The hazard ratio of the primary outcome was 0.99; 95% CI, 0.72 to 1.37; P = 0.97 in patients without prevalent hypertension, and 1.14; 95% CI, 0.83 to 1.54; P = 0.42 in patients with prevalent hypertension. Conclusions In patients resuscitated after OHCA, there was a significant association between age and the primary composite outcome of death, severe disability, or coma. The effect of BP target on the primary outcome did not appear to differ according to age groups or prevalent hypertension. Therefore, age and prevalent hypertension should not influence the choice of BP targets after OHCA.

Abstract #1407267: In-hospital Outcomes of Myxedema Coma in Teaching Vs Non-teaching Hospitals

Many studies have analyzed current data on outcomes at teaching vs non-teaching hospitals, and the results have been found to be dissimilar in certain hospitalizations in the United States. this study set out to examine the differences in healthcare outcomes between teaching and non-teaching hospitals in patients who were admitted for myxedema coma using a nationally representative sample. We reviewed data from the National Inpatient Sample (NIS) of patients between 2016-2019. Using ICD-10 diagnosis codes, we identified patients who were admitted due to myxedema coma within the study period. We further categorized our study population into 2 groups based on teaching vs non-teaching status. Multivariate analysis was done to investigate the in-hospital outcomes between both groups and adjust for confounders. During the study period, 3,839 myxedema coma admissions were identified. Teaching hospitals received 70.7% (2,715) of these admissions, while non-teaching hospitals received 29.3% (1,124). The mean age of the cohort was 66 years, 70% were females and 69% were white. The mean length of stay (LOS) was 9.4 days and the average total hospital charge was 89,068 $. There was no significant difference in in-hospital mortality in both groups (OR 1.23, 95% CI 0.66 -2.27, p=0.507). The teaching hospital group had increased odds of acute respiratory failure (OR 1.6, 95% CI 1.07 – 2.4, p = 0.021), acute kidney injury (OR 1.48, 95% CI 1.04 – 2.1, p = 0.028), and bradycardia (OR 1.67, 95% CI 1.06 – 2.6, p = 0.025). No significant risk difference between the two groups in terms of hyponatremia (OR 0.91, 95% CI 0.6 – 1.36, p= 0.66), pericardial effusion (OR 0.87, 95% CI 0.41 – 1.8, p= 0.719) or sepsis (OR 1.38, 95% CI 0.69 – 2.7, p= 0.353). Hospital teaching status was associated with an increased mean LOS (10 vs 7.9 days, p=0.002) and mean total hospital charges (93,122 vs 79,336 $, p=0.035). The study clearly showed that patients admitted with myxedema coma in teaching hospitals have an increased risk of in-hospital outcomes including acute respiratory failure, acute kidney injury, and bradycardia compared to non-teaching hospitals. Teaching hospital status was not associated with increased in-hospital mortality in myxedema coma admissions.

Auditory stimulation and deep learning predict awakening from coma after cardiac arrest.

Assessing the integrity of neural functions in coma after cardiac arrest remains an open challenge. Prognostication of coma outcome relies mainly on visual expert scoring of physiological signals, which is prone to subjectivity and leaves a considerable number of patients in a 'grey zone', with uncertain prognosis. Quantitative analysis of EEG responses to auditory stimuli can provide a window into neural functions in coma and information about patients' chances of awakening. However, responses to standardized auditory stimulation are far from being used in a clinical routine due to heterogeneous and cumbersome protocols. Here, we hypothesize that convolutional neural networks can assist in extracting interpretable patterns of EEG responses to auditory stimuli during the first day of coma that are predictive of patients' chances of awakening and survival at 3 months. We used convolutional neural networks (CNNs) to model single-trial EEG responses to auditory stimuli in the first day of coma, under standardized sedation and targeted temperature management, in a multicentre and multiprotocol patient cohort and predict outcome at 3 months. The use of CNNs resulted in a positive predictive power for predicting awakening of 0.83 ± 0.04 and 0.81 ± 0.06 and an area under the curve in predicting outcome of 0.69 ± 0.05 and 0.70 ± 0.05, for patients undergoing therapeutic hypothermia and normothermia, respectively. These results also persisted in a subset of patients that were in a clinical 'grey zone'. The network's confidence in predicting outcome was based on interpretable features: it strongly correlated to the neural synchrony and complexity of EEG responses and was modulated by independent clinical evaluations, such as the EEG reactivity, background burst-suppression or motor responses. Our results highlight the strong potential of interpretable deep learning algorithms in combination with auditory stimulation to improve prognostication of coma outcome.

Criteria of reversibility of suppression of bioelectric activity of the brain in alcoholic coma: experimental study

The aim. The aim of the study is to determine prognostically significant criteria for the reversibility of the suppression of the generation of bioelectrical activity using an experimental model of alcoholic coma. Materials and methods. The work was performed on 27 nonlinear sexually mature rats weighing 340±40 g, which received a 40% solution of ethyl alcohol by the oral route in fractional doses of 12.6 g/kg, which corresponded to LD50. EEG monitoring was performed until there was a definite effect (from 1 to 54 hours). Results. In a favorable outcome of alcoholic coma (11 rats), the EEG results contained the following phase states: 1) a pattern of continuous activity with registration of flashes with intense modulation amplitudes (modulation coefficient 10-12, index 25-35%); 2) a pattern of discrete activity (signal suppression index does not exceed 10%), which was recorded only in the toxicogenic phase; 3) a pattern of awakening. In the lethal outcome of cerebral insufficiency (16 rats), there were the following states of bioelectric activity: 1) weakly modulated continuous activity (modulation coefficient is less than 5); 2) fragmented activity (suppression index is 20-50%); 3) “flash-suppression” pattern; 4) a pattern of periodic discharges; 5) isoelectric silence. The terminal phase of cerebral insufficiency was characterized by the presence of high-amplitude waves with a frequency of 1-1.5 Hz, alternating with 3-4 oscillations decreasing in amplitude. Conclusion. In a case of acute poisoning with ethanol at a dose of LD50, the prognostically favorable EEG sign is the amplitude modulation of continuous activity, which reflects the preservation of synchronizing thalamocortical interactions. In the toxicogenic phase of the poisoning, a pattern of discrete activity can be recorded (modulation index is up to 10%), which reflects the suppressive effect of ethanol rather than the decay of the bioelectrogenesis mechanisms.

Metabolomic Profiling of the Blood of Patients with Chronic Consciousness Disorders

The main variants of chronic consciousness disorder (CCD) developing in adverse coma outcome are vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimal consciousness state (MCS). The aim of the study was to investigate the main differences in metabolomic abnormalities in patients with VS / UWS and MCS, as well as to identify changes in metabolomics depending on sleep or wakefulness phase. Materials and Methods. Untargeted metabolome analysis of blood plasma of 10 patients in VS / UWS (group 1) and 6 patients in MCS (group 2) was performed using reversed-phase and hydrophilic chromatography methods. The underlying conditions of brain injury were TBI (2 in group 1 and 5 in group 2) and hypoxia (8 in group 1 and 1 in group 2). The internal jugular vein was catheterized in all patients, and blood was collected while awake during the daytime for 2 days. Aliquots of pooled plasma samples were purified from protein components and analyzed by high-performance liquid chromatography in two modes: reversed-phase and hydrophilic ones. Mass-spectrometric detection was performed in full ion current scanning mode: registration of positively charged ions in the m/z range from 50 to 1300 a.u. Data were adjusted and normalized using MS-DIAL software ver. 4.70 software; differences were identified using analysis of variance, discriminant and cluster analysis. The data were analyzed and visualized using MetaboAnalyst 5.0 software (https://www.metaboanalyst.ca). Results. Four major metabolites (at VIP &gt; 0.5), which content was most modulated depending on the study group, were identified including 4 (m/z 124.0867, Rt = 17.67, p &lt; 0.01), 33 (m/z 782.5722, Rt = 17.69, p &lt; 0.01), 6 (m/z 125.0904, Rt = 18.43, p &lt; 0.01) and 1 (m/z 463.2304, Rt = 15.78, p &lt; 0.01), with no significant differences between daytime and nighttime blood samples. Significant quantitative differences were shown for three metabolites in the groups, 14 (m/z 162.1126, Rt = 10.28, p &lt; 0.01), 35 (m/z 780.5483, Rt = 7.65, p &lt; 0.01), and 41 (m/z 806.5649, Rt = 7.58, p &lt; 0.01), and four metabolites when comparing the daytime and nighttime samples: 14 (m/z 162.1126, Rt = 10.28, p = 0.0201), 35 (m/z 780.5483, Rt = 7.65, p &lt; 0.01), 41 (m/z 806.5649, Rt = 7.58, p &lt; 0.01), and 48 (m/z 848.5354, Rt = 7.65, p &lt; 0.01). Conclusion. Untargeted metabolomic analysis confirmed the hypothesis of likely significant quantitative and qualitative differences in metabolite composition depending on the type of CCD and circadian rhythm. The study established a set of metabolites that are potential biomarkers for differential diagnosis of VS/UWS and MCS including 4, 33, 6, 1 (in the experiment on the reversed-phase column) and 14, 35, 41, 48 (in the experiment on the hydrophilic column), based on their significant contribution to intergroup and intragroup differences. Further studies will be aimed to characterize the identified metabolites.

Preoperative scale proposal based on clinical outcome for elderly patients with ruptured intracranial aneurysms undergoing microsurgery

Introduction Life expectancy in individuals has increased in recent years. There is no consensus in the literature on the best treatment for a ruptured aneurysm in the elderly (> 60 years), but some places only have microsurgery as a therapeutic strategy. This work aims to develop a prognostic scale for ruptured intracranial aneurysms in the elderly. Material and Methods Two thousand five hundred thirty patients with subarachnoid hemorrhage were retrospectively evaluated in the last ten years, and 550 of them were elderly. We developed a prognostic scale from the analysis of medical records, clinical and tomographic features that had statistical significance. Glasgow Coma Outcome (GOS) was the outcome of interest and p value < 0,05 was considered statistically significant. Results Five hundred fifty patients were evaluated, and the comorbidities that were independent variables for poor prognosis were smoking and arterial hypertension; clinical variables were Hunt-Hess, modified Rankin and Glasgow Coma Scale; tomographic was Fisher scale. Poor outcome was defined as GOS ≤ 3. Poor surgical outcomes were more remarkable in the high-risk factor categories, being 6.41 times higher among individuals who had 3 to 4 risk factors and 8.80 times higher among individuals with 5 to 6 risk factors. Conclusion In some vascular neurosurgery services worldwide, microsurgery is the only therapeutic option. This scale aimed at the elderly patient individualizes the treatment and can predict the clinical outcome in ruptured intracranial aneurysms.

Electrophysiological correlates of thalamocortical function in acute severe traumatic brain injury

Tools assaying the neural networks that modulate consciousness may facilitate tracking of recovery after acute severe brain injury. The ABCD framework classifies resting-state EEG into categories reflecting levels of thalamocortical network function that correlate with outcome in post-cardiac arrest coma. In this longitudinal cohort study, we applied the ABCD framework to 20 patients with acute severe traumatic brain injury requiring intensive care (12 of whom were also studied at ≥6-months post-injury) and 16 healthy controls. We tested four hypotheses: 1) EEG ABCD classifications are spatially heterogeneous and temporally variable; 2) ABCD classifications improve longitudinally, commensurate with the degree of behavioral recovery; 3) ABCD classifications correlate with behavioral level of consciousness; and 4) the Coma Recovery Scale-Revised arousal facilitation protocol yields improved ABCD classifications. Channel-level EEG power spectra were classified based on spectral peaks within pre-defined frequency bands: ‘A’ = no peaks above delta (<4 Hz) range (complete thalamocortical disruption); ‘B’ = theta (4–8 Hz) peak (severe thalamocortical disruption); ‘C’ = theta and beta (13–24 Hz) peaks (moderate thalamocortical disruption); or ‘D’ = alpha (8–13 Hz) and beta peaks (normal thalamocortical function). Acutely, 95% of patients demonstrated ‘D’ signals in at least one channel but exhibited within-session temporal variability and spatial heterogeneity in the proportion of different channel-level ABCD classifications. By contrast, healthy participants and patients at follow-up consistently demonstrated signals corresponding to intact thalamocortical network function. Patients demonstrated longitudinal improvement in ABCD classifications (p < .05) and ABCD classification distinguished patients with and without command-following in the subacute-to-chronic phase of recovery (p < .01). In patients studied acutely, ABCD classifications improved after the Coma Recovery Scale-Revised arousal facilitation protocol (p < .05) but did not correspond with behavioral level of consciousness. These findings support the use of the ABCD framework to characterize channel-level EEG dynamics and track fluctuations in functional thalamocortical network integrity in spatial detail.

Role of Decompressive Craniectomy in severe Traumatic Brain Injury: An Institutional Experience

Objective: The present study was designed to assess the outcome following the Decompressive Craniectomy procedures performed in our setup for patients presenting with severe traumatic brain injury.&#x0D; Materials and Methods: This was a retrospective study wherein the medical records of adult patients that presented with an initial Glasgow Coma Scale (GCS) ? 8 and in whom decompressive craniectomy had been carried out for severe traumatic brain injury were retrospectively analyzed. Patients in whom decompressive craniectomy had been carried out for causes other than trauma and patients with initial GCS ? 9 were excluded from the study. The studied parameters included age, sex, initial GCS, computed tomography (CT) brain diagnosis, and the outcome according to the Glasgow coma outcome scale (GOS).&#x0D; Results: The study included 12 patients, and of these 12 patients operated with Decompressive Craniectomy for severe traumatic brain injury only 2 survived. The mortality was 83.3%. The initial GCS and age were not statistically different between the survivors and the non-survivors. Based on the Glasgow Outcome Scale (GOS) only 1 patient had a good outcome. Overall, an unfavorable outcome based on the GOS score was seen in 91.7% of patients.&#x0D; Conclusion: Our study concludes that Decompressive Craniectomy is associated with high mortality in patients presenting with severe traumatic brain injury and does not seem to offer a better alternative to standard medical management.

MRI markers of brain network integrity relate to neurological outcome in postanoxic coma

AimCurrent multimodal approaches leave approximately half of the comatose patients after cardiac arrest with an indeterminate prognosis. Here we investigated whether early MRI markers of brain network integrity can distinguish between comatose patients with a good versus poor neurological outcome six months later. MethodsWe performed a prospective cohort study in 48 patients after cardiac arrest submitted in a comatose state to the Intensive Care Unit of two Dutch hospitals. MRI was performed at three days after cardiac arrest, including resting state functional MRI and diffusion-tensor imaging (DTI). Resting state fMRI was used to quantify functional connectivity within ten resting-state networks, and DTI to assess mean diffusivity (MD) in these same networks. We contrasted two groups of patients, those with good (n = 29, cerebral performance category 1–2) versus poor (n = 19, cerebral performance category 3–5) outcome at six months. Mutual associations between functional connectivity, MD, and clinical outcome were studied. ResultsPatients with good outcome show higher within-network functional connectivity (fMRI) and higher MD (DTI) than patients with poor outcome across 8/10 networks, most prominent in the default mode network, salience network, and visual network. While the anatomical distribution of outcome-related changes was similar for functional connectivity and MD, the pattern of inter-individual differences was very different: functional connectivity showed larger inter-individual variability in good versus poor outcome, while the opposite was observed for MD. Exploratory analyses suggested that it is possible to define network-specific cut-off values that could help in outcome prediction: (1) high functional connectivity and high MD, associated with good outcome; (2) low functional connectivity and low MD, associated with poor outcome; (3) low functional connectivity and high MD, associated with uncertain outcome. DiscussionResting-state functional connectivity and mean diffusivity-three days after cardiac arrest are strongly associated with neurological recovery-six months later in a complementary fashion. The combination of fMRI and MD holds potential to improve prediction of outcome.

Aetiology and outcome of non-traumatic coma in African children: protocol for a systematic review and meta-analysis

BackgroundNon-traumatic coma is a common acute childhood presentation to healthcare facilities in Africa and is associated with high morbidity and mortality. Historically, the majority of cases were attributed to cerebral malaria (CM). With the recent drastic reduction in malaria incidence, non-malarial coma is becoming a larger proportion of cases and determining the aetiology is diagnostically challenging, particularly in resource-limited settings. The purpose of this study will be to evaluate the aetiology and prognosis of non-traumatic coma in African children.MethodsWith no date restrictions, systematic searches of MEDLINE, Embase, and Scopus will identify prospective and retrospective studies (including randomised controlled trials, cluster randomised trials, cohort studies, cross-sectional, and case-control studies) recruiting children (1 month–16 years) with non-traumatic coma (defined by Blantyre Coma Score ≤ 2 or comparable alternative) from any African country. Disease-specific studies will be included if coma is associated and reported. The primary outcome is to determine the aetiology (infectious and non-infectious) of non-traumatic coma in African children, with pooled prevalence estimates of causes (e.g., malaria). Secondary outcomes are to determine overall estimates of morbidity and mortality of all-cause non-traumatic coma and disease-specific states of non-traumatic coma, where available. Random effects meta-analysis will summarise aetiology data and in-hospital and post-discharge mortality. Heterogeneity will be quantified with τ2, I2, and Cochran’s Q test.DiscussionThis systematic review will provide a summary of the best available evidence on the aetiology and outcome of non-traumatic coma in African children.Systematic review registrationPROSPERO CRD42020141937

Processed Electroencephalographic Use During Anesthesia and Outcomes: Analysis of The Society of Thoracic Surgeons Adult Cardiac Surgery Database

BackgroundThis study assessed associations between processed electroencephalographic (pEEG) use during anesthesia, surgery- and anesthesia-related risk factors, and neurologic outcomes and mortality after cardiac surgery. MethodsDrawing from The Society of Thoracic Surgeons Adult Cardiac Surgery Database and its Adult Cardiac Anesthesiology Section, we identified 42 932 records for elective, urgent, and emergency cardiac surgical procedures between July 1, 2017 and December 31, 2019. Using propensity score-weighted regression analysis, we analyzed the associations between pEEG use during anesthesia on the primary outcome, postoperative delirium (POD), and secondary outcomes of stroke, encephalopathy, coma, and operative mortality. ResultsThe rate of pEEG use during anesthesia use was 32.8% (n = 14 086), and its use was not associated with decreased odds for POD (odds ratio [OR], 0.88; 95% CI, 0.78-1.02) or encephalopathy (OR, 0.85; 95% CI, 0.70-1.03). Intraoperative pEEG monitoring use was also not associated with increased odds for stroke (OR, 1.17; 95% CI, 0.97-1.42) or coma (OR, 1.44; 95% CI, 0.82-2.52). In contrast, pEEG use during anesthesia was associated with higher odds for operative mortality (OR, 1.23; 95% CI, 1.05-1.44). This association remained significant after adjusting for POD (OR, 1.21; 95% CI, 1.03-1.41), stroke (OR, 1.21; 95% CI, 1.04-1.42), and encephalopathy (OR, 1.28; 95% CI, 1.07-1.52). ConclusionsThis large retrospective database study found no association between pEEG use during cardiac surgery and postoperative neurologic outcomes such as POD, stroke, encephalopathy, or coma. However, patients who underwent pEEG monitoring during anesthesia experienced higher mortality, even after adjustment for neurologic outcomes.