Prediction Of Neurological Outcome Research Articles

The occurrence of shivering in cardiac arrest survivors undergoing therapeutic hypothermia is associated with a good neurologic outcome

BackgroundThe incidence of shivering in cardiac arrest survivors who undergo therapeutic hypothermia (TH) is varied. Its occurrence is dependent on the integrity of multiple peripheral and central neurologic pathways. We hypothesized that cardiac arrest survivors who develop shivering while undergoing TH are more likely to have intact central neurologic pathways and thus have better neurologic outcome as compared to those who do not develop shivering during TH. MethodsProspectively collected data on consecutive adult patients admitted to a tertiary center from 1/1/2007 to 11/1/2010 that survived a cardiac arrest and underwent TH were retrospectively analyzed. Patients who developed shivering during the cooling phase of TH formed the “shivering” group and those that did not formed the “non-shivering” group. The primary end-point: Pittsburgh Cerebral Performance Category (CPC) scale; good (CPC 1–2) or poor (CPC 3–5) neurological outcome prior to discharge from hospital. ResultsOf the 129 cardiac arrest survivors who underwent TH, 34/94 (36%) patients in the “non-shivering” group as compared to 21/35 (60%) patients in the “shivering” group had good neurologic outcome (P=0.02). After adjusting for confounders using binary logistic regression, occurrence of shivering (OR: 2.71, 95% CI 1.099–7.41, P=0.04), time to return of spontaneous circulation (OR: 0.96, 95% CI 0.93–0.98, P=0.004) and initial presenting rhythm (OR: 4.0, 95% CI 1.63–10.0, P=0.002) were independent predictors of neurologic outcome. ConclusionThe occurrence of shivering in cardiac arrest survivors who undergo TH is associated with an increased likelihood of good neurologic outcome as compared to its absence.

Abstract 218: Cerebral Oximetry as a Post-ROSC Predictor of Neurologic Outcome After OOHCA

No reliable early predictors of neurological outcome exist for patients resuscitated from an OOHCA. Objectives: We investigated the prognostic utility of cerebral oximetry (rSO2) obtained after Return of Spontaneous Circulation (ROSC) on neurological outcome after OOHCA. Methods: This IRB approved, observational trial collected data on a convenience sample of patients presenting to an academic, urban Emergency Department with OOHCA. Cerebral Oximetry uses near infrared spectroscopy to measure oxygen in the brain independent of pulse using adhesive rSO2sensors that were placed on patient’s forehead upon ED arrival and data recorded for at least 4 hours post ROSC. We followed Utstein criteria for demographics and data recording. Blinded investigators abstracted CPC scores for all patients. Outcome measure defined as good CPC (≤ 2) at hospital discharge. We analyzed data with descriptive statistics and logistic regression. Results: We analyzed 32 patients: 69% were male, mean age 62.5 years (52 to 75), 30 (93.8%) witnessed and 23 (71.9%) had bystander CPR. Initial rhythm was VF/VT 19%, PEA 40%, Asystole 34% and 2 unknown. There were 7 (22%) with good CPC at hospital discharge. Univariate analysis showed only the average rSO2 during first 4-hours post ROSC predictive of good outcome (p<0.003). Initial Mean Arterial Pressure (MAP) was a good prognosticator (p<0.087). Logistic regression revealed only average rSO2 4-hours post ROSC as indicative of good outcome (p<0.086). Conclusion: The average cerebral oximetry in the first 4 hours post ROSC was an excellent predictor of good neurological outcome at hospital discharge. This study is limited by small sample size and observational nature.

Abstract 19470: Presence of Anemia at Induction of Therapeutic Hypothermia as a Predictor of Neurological Outcome in Cardiac Arrest Survivors

Introduction: Therapeutic hypothermia (TH) has become an accepted practice to improve neurological outcome in survivors of cardiac arrest. Co-morbid factors that may impact neurological outcome in such patients are not well understood. Anemia has been shown to have a prognostic value in a wide variety of diseases. We investigated the effect of hematocrit on neurological outcome in cardiac arrest survivors undergoing TH. Methods: A retrospective analysis was performed on 196 consecutive cardiac arrest survivors who underwent TH with endovascular cooling in the cardiac intensive care unit at a tertiary care center between January 2007 and April 2012. Patients were divided into two groups based on anemia as per their hematocrit (Hct) value at induction of TH (Hct≤36 and Hct>36). The primary endpoint was measured using the Pittsburgh cerebral performance category (CPC) scale and patients were assessed for a good (CPC 1 and 2) or poor (CPC 3-5) neurological outcome prior to discharge from hospital. Results: Of the 196 patients, 130 patients (66 %) had a Hct ≤ 36 and 66 patients (34 %) had a Hct > 36. Forty two (32%) patients with Hct ≤ 36 and 25 patients (38%) with Hct>36 had a good neurologic outcome (P=0.50) (Figure 1) . On multivariable analysis, initial/presenting rhythm (OR: 8.752; 95 % CI 2.60-29.40, P< 0.001) and time to return of spontaneous circulation (OR: 0.942; 95 % CI 0.90-0.99, P=0.02) were independent predictors of neurologic outcome. Conclusion: Presence of anemia at induction of TH is not associated with neurological outcome in cardiac arrest survivors.

Abstract 257: Clinical Decision Tree Model in Patients with Out-of-Hospital Cardiac Arrest for Predicting Neurological Outcome at the Emergency Department

Introduction: The ideal factors for predicting neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA) remain elusive. Hypothesis: We hypothesized that a novel decision tree model using 4 pre-hospital variables can predict neurological outcome after OHCA at the emergency department. Methods: We analyzed 390226 adults in whom resuscitation was attempted after non-traumatic OHCAs in a prospectively recorded nationwide Utstein-style database in Japan over 5 years (2005-2009). The endpoint was 1-month survival with good neurological outcome (cerebral performance category scale, 1-2). We developed a prediction model using data from 4 years (2005-2008, n = 307896), with validation using external data from 2009 ( n = 82330). Results: Overall 1-month survival and good neurological outcome rates were 4.19% and 1.99%, respectively. Multivariate logistic regression analysis indicated the following pre-hospital factors to be significant: shockable initial rhythm (odds ratio [OR] 5.87; 95% confidence interval [CI] 5.23-6.60), emergency medical service (EMS) personnel witnessed (OR 3.40; 95%CI 3.15-3.69), witnessed arrest (OR 3.05; 95%CI 2.83-3.28), and age (OR 3.24; 95%CI 2.97-3.53). Using recursive partitioning analysis with these 4 predictors, we developed a clinical decision tree model: if a witnessed OHCA patient had shockable initial rhythm, the probability of good outcome was 20.0% (age<71) or 10.3% (age>or=71); if an unwitnessed OHCA patient had shockable initial rhythm, the probability of good outcome was 6.8% (age<81) or 1.8% (age>or=81); if a witnessed OHCA patient had unshockable initial rhythm, the probability of good outcome was 3.8% (EMS personnel witnessed arrest) or 1.1% (EMS personnel unwitnessed arrest); if an unwitnessed OHCA patient had unshockable initial rhythm, the probability of good outcome was 0.5% (age<71) or 0.2% (age>or=71). The c-statistics for this model in the groups for development and validation were 0.867 (95%CI 0.861-0.873) and 0.887 (95%CI 0.877-0.896), respectively. Conclusions: Stratification of patients using a decision tree model accurately provides the severity of OHCA classification rules and can predict good neurological outcomes after OHCA at the emergency department.

Abstract 235: The Glasgow Motor Score Before Induction of Therapeutic Hypothermia Is an Independent Predictor of Good Outcome in Cardiac Arrest

Background: With the recent introduction of therapeutic hypothermia, the application of sedation becomes necessary in cardiac arrest patients. Therefore early prediction of neurologic outcome in these patients is challenging problem. Nevertheless neurologic examination including the Glasgow coma scale should be basis for decision making. So, we investigated the usefulness of the Glasgow motor score before induction of therapeutic hypothermia for outcome prediction in survivors of cardiac arrest treated with therapeutic hypothermia. Methods: Between March 2009 and July 2011, patients who successfully resuscitated from cardiac arrest and treated with mild therapeutic hypothermia were included in this study. Data were collected by local post-cardiac arrest care registry. Neurologic outcome was assessed with Cerebral Performance Category (CPC) at hospital discharge and good neurologic outcome was defined CPC score of 1 and 2. Results: Total 89 patients were treated with therapeutic hypothermia during study period. Among these patients, 39 were good neurologic outcome and 50 were poor neurologic outcome. The value for prediction of good outcome was as follows: sensitivity 53.8%, specificity 96.0%, PPV 91.3%, NPV 72.7% and AUC 0.749. Conclusions: The results of this study show that the Glasgow motor score > 1 before induction of therapeutic hypothermia is an independent predictor of good outcome in patients treated with therapeutic hypothermia. Thus, the patients with the Glasgow motor score > 1 soon after ROSC should be treated aggressively including therapeutic hypothermia.

Neurological assessment in infants discharged from a neonatal intensive care unit

BackgroundLongitudinal motor assessment in infants at different neurodevelopmental risk has not been previously evaluated using structured assessments. AimTo verify if the Hammersmith Infant Neurological Examination (HINE) is a good tool to predict the neuromotor outcome in infants discharged from a level II–III Neonatal Intensive Care Unit (NICU) MethodsIn this cohort analysis, 1541 infants discharged from our NICU between January of 2002 and the April 2006 were enrolled and assessed using the HINE at 3, 6, 9, 12 months. At two years, these infants were further assessed, and grouped into infants with normal outcome (1150), with mild disability (321) and with cerebral palsy (70), ResultsCorrelation analysis of Spearman showed a significant (p < 0.0001) and moderate (r2 = −0.55 to −0.73) negative correlation between HINE scores (3, 6, 9, 12 months) and neurological outcome at two years. Cut-off scores for each assessment' age were provided as predictive value for cerebral palsy. DiscussionThis study mainly showed that HINE, as soon as the first months of life, helps in the process of prediction of neurological outcome at two years of age in a heterogeneous population of infants discharged from an NICU.

Continuous electroencephalography monitoring for early prediction of neurological outcome in postanoxic patients after cardiac arrest

To evaluate the value of continuous electroencephalography in early prognostication in patients treated with hypothermia after cardiac arrest. Prospective cohort study. Medical intensive care unit. Sixty patients admitted to the intensive care unit for therapeutic hypothermia after cardiac arrest. None. In all patients, continuous electroencephalogram and daily somatosensory evoked potentials were recorded during the first 5 days of admission or until intensive care unit discharge. Neurological outcomes were based on each patient's best achieved Cerebral Performance Category score within 6 months. Twenty-seven of 56 patients (48%) achieved good neurological outcome (Cerebral Performance Category score 1-2).At 12 hrs after resuscitation, 43% of the patients with good neurological outcome showed continuous, diffuse slow electroencephalogram rhythms, whereas this was never observed in patients with poor outcome.The sensitivity for predicting poor neurological outcome of low-voltage and isoelectric electroencephalogram patterns 24 hrs after resuscitation was 40% (95% confidence interval 19%-64%) with a 100% specificity (confidence interval 86%-100%), whereas the sensitivity and specificity of absent somatosensory evoked potential responses during the first 24 hrs were 24% (confidence interval 10%-44%) and 100% (confidence interval: 87%-100%), respectively. The negative predictive value for poor outcome of low-voltage and isoelectric electroencephalogram patterns was 68% (confidence interval 50%-81%) compared to 55% (confidence interval 40%-60%) for bilateral somatosensory evoked potential absence, both with a positive predictive value of 100% (confidence interval 63%-100% and 59%-100% respectively). Burst-suppression patterns after 24 hrs were also associated with poor neurological outcome, but not inevitably so. In patients treated with hypothermia, electroencephalogram monitoring during the first 24 hrs after resuscitation can contribute to the prediction of both good and poor neurological outcome. Continuous patterns within 12 hrs predicted good outcome. Isoelectric or low-voltage electroencephalograms after 24 hrs predicted poor outcome with a sensitivity almost two times larger than bilateral absent somatosensory evoked potential responses.

158 Utility Cranial Nerve Testing Obtained in the Emergency Department as Early Predictors of Neurologic Outcome Post Cardiac Arrest

158 Utility Cranial Nerve Testing Obtained in the Emergency Department as Early Predictors of Neurologic Outcome Post Cardiac Arrest

Clinical predictors of neurological outcome, functional status, and survival after traumatic spinal cord injury: a systematic review

The object of this study was to identify, by means of a systematic review of the literature, the acute clinical predictors of neurological outcome, functional outcome, and survival after traumatic spinal cord injury (SCI). A comprehensive computerized literature review search was performed, using MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews. Selected articles were classified according to their level of evidence. Articles were then stratified into one of 3 domains depending on whether the primary focus was clinical prediction of 1) neurological outcome, 2) functional status, or 3) survival. For each study selected, clinical predictors related to patient demographic characteristics, injury mechanism, or neurological examination findings were extracted, and the individual relationship to outcome was defined. The initial search resulted in 376 citations. After application of the inclusion and exclusion criteria and study review, 51 relevant articles were identified and graded. Of these, 25 provided predictors for neurological outcome, 22 for functional outcome, and 15 for survival, with several of the articles providing information on more than one type of outcome. All of the included studies were designated as providing Class I, II, or III levels of evidence. The severity of neurological injury (as measured by admission Americal Spinal Injury Association Impairment Scale grade, Frankel grade, or injury completeness), level of injury, and the presence of a zone of partial preservation were consistent predictors of neurological outcome. Severity of neurological injury, level of injury, reflex pattern, and age were consistent predictors of functional outcome. Finally, severity of neurological injury, level of injury, age, and the presence of multisystem trauma seen with higher-energy injury mechanisms were consistent predictors of survival. On the basis on this review, the authors have identified a constellation of acute clinical features that may help to define an individual's profile for recovery and survival after SCI. This study will help to facilitate communication in the clinical realm and assist in classifying subsets of patients within future clinical studies.

‘Long’ pressure reactivity index (L-PRx) as a measure of autoregulation correlates with outcome in traumatic brain injury patients

Cerebral autoregulation and, consequently, cerebrovascular pressure reactivity, can be disturbed after traumatic brain injury (TBI). Continuous monitoring of autoregulation has shown its clinical importance as an independent predictor of neurological outcome. The cerebral pressure reactivity index (PRx) reflects that changes in seconds of cerebrovascular reactivity have prognostic significance. Using an alternative algorithm similar to PRx, we investigate whether the utilization of lower-frequency changes of the order of minutes of mean arterial blood pressure (MAP) and intracranial pressure (ICP) could have a prognostic value in TBI patients. Head-injured patients requiring continued advanced multimodal monitoring, including hemodynamic, ICP and microdialysis (MD) monitoring, were analyzed retrospectively. A low-frequency sample pressure reactivity index (L-PRx) was calculated, using 20-min averages of MAP and ICP data as a linear Pearson's correlation. The mean values per patient were correlated to outcome at 6 months after injury. Differences of monitoring parameters between non-survivors and survivors were compared. A total of 29 patients (mean age 37.2 years, 26 males) suffering from TBI were monitored for a mean of 109.6 h (16-236 h, SD ± 60.4). Mean L-PRx was found to be of 0.1 (-0.2 to 0.6, SD ± 0.20), six patients presented impaired (>0.2) values. The averaged L-PRx correlated significantly with ICP (r = 0.467, p = 0.011) and 6-month outcome (r = -0.556, p = 0.002). Significant statistical differences were found in L-PRx, cerebral perfusion pressure (CPP), lactate, and lactate-pyruvate ratio when comparing patients who died (n = 5) and patients who survived. L-PRx correlates with the 6-month outcome in TBI patients. Very slow changes of MAP and ICP may contain important autoregulation information. L-PRx may be an alternative algorithm for the estimation of cerebral autoregulation and clinical prognosis.

Clinical and radiographic predictors of neurological outcome following posterior fossa decompression for spontaneous cerebellar hemorrhage

Spontaneous cerebellar hemorrhage often requires surgical suboccipital decompression and clot evacuation. Predictors of postoperative neurological deficits and outcome are not widely addressed in the literature. A retrospective review was conducted on 37 consecutive patients with the diagnosis of cerebellar hemorrhage requiring suboccipital decompression and clot evacuation. Clinical and radiographic variables were analyzed. Outcome measures were postoperative Glasgow Coma Scale (GCS) score, and long-term outcome measured by Rankin score and Glasgow Outcome Scale (GOS) score. A multivariate statistical analysis was conducted. The average age of patients was 71.1years. There was significant improvement of neurological exam from a mean preoperative GCS score of 8.8 to a mean postoperative GCS score of 13.0. The mortality rate was 37.9%. According to the Rankin scale, 58.6% were functionally independent, 3.4% had a moderate disability, and none had a major disability or was in a vegetative state. Using GOS score, 62.1% had a favorable outcome. The presence of multiple comorbidities was associated with worse postoperative GCS and long-term outcome. A worse preoperative neurological exam, age older than 70years, and the presence of intraventricular hemorrhage correlated only with a worse postoperative exam but not with the long-term outcome. Patients improve neurologically after posterior fossa decompression for cerebellar hemorrhage and a high percentage attain long-term functional outcome. Only the presence of multiple clinical comorbidities was associated with a worse outcome. Since there are no other preoperative predictors of long-term outcome, we recommend suboccipital decompression, when indicated, for patients with cerebellar hemorrhage regardless of age, hematoma size, or preoperative neurological exam.

Spinal Cord Compression

Malignant epidural spinal cord compression (MESCC) remains a common neuro-oncologic emergency with high associated morbidity. Despite widespread availability of MRI, the diagnosis frequently goes unmade until myelopathy supervenes, which is unfortunate because the strongest predictor of neurologic outcome with treatment is the neurologic status when treatment is initiated. Once the diagnosis of MESCC is suspected, patients with neurologic deficits should be started on high-dose corticosteroids (eg, dexamethasone, 10-100mg intravenously, followed by 16 to 100mg/d in divided doses). Definitive therapy of MESCC almost always includes radiation therapy and in some cases surgical intervention; factors considered include the patient's performance status and extent of visceral and skeletal disease, spinal stability, the tumor's underlying radiosensitivity, and the degree of spinal cord compression. Patients with spinal instability or radioresistant tumors are likely to have a much better neurologic outcome with tumor resection and spinal stabilization prior to radiation; the same may also pertain to patients with moderately radiosensitive tumors who have good life expectancy in terms of their systemic tumor. Conventional radiation has historically been beneficial after surgery and in patients who are not surgical candidates. Recent studies suggest a role for stereotactic body radiation therapy in patients with spinal metastasis from radioresistant tumors and in patients who have received prior standard radiotherapy, so long as the spinal cord has been decompressed.

Early neurological outcome prediction model after bystander-witnessed out-of-hospital cardiac arrest: a nationwide population-based study

Identification of prehospital prognostic factors in out-of-hospital cardiac arrests (OHCAs) with prehospital return of spontaneous circulation (ROSC) and establishment of a prediction model for survival with favorable neurological outcome may minimize the costs and save the medical resources. In this study, we developed a best model for predicting 1-month survival with favorable neurological outcome (defined as Glasgow-Pittsburgh cerebral performance category (CPC) scale = 1 or 2), using a logistic regression analysis.

Beyond herniation

Few data are available on the use of brainstem auditory evoked potentials (BAEPs) in combination with other electrophysiological tools to assess prognosis of comatose survivors from cardiac arrest (CA).Retrospective analysis of data from all adult patients (>18 years of age) admitted to our Dept of Intensive Care after CA over a 6-year period who were comatose (Glasgow Coma Scale <9) on admission, had been treated with targeted temperature management and had BAEP testing. We collected variables related to CA, as well as electroencephalography (EEG) findings, N20 somatosensory evoked potentials, and the presence of I, III and/or V waves on BAEP testing. Outcome was assessed at 3 months using the Cerebral Performance Categories (3–5 = poor outcome).We studied 65 patients; 48 (74%) had a poor neurological outcome. BAEP assessment was performed day 3 [3,4] after the CA. At least one of the three waves was absent bilaterally in 34 patients (52%); of these patients, 29 (85%) had a poor neurological outcome (sensitivity 60%, specificity 71%, positive predictive value [PPV] 85% and negative predictive value [NPV] 39%). Three patients (5%) had bilateral absence of all three waves, all of whom had a poor neurological outcome.In this series of patients after CA, at least one of the BAEP waves was absent bilaterally in half the survivors; however, their use for prediction of poor neurological outcome remains limited.

Anesthetic Management and Outcome in Patients during Endovascular Therapy for Acute Stroke

Studies of endovascular treatment for acute ischemic stroke have identified general anesthesia as a predictor for poor outcome in comparison with local anesthesia/sedation. This retrospective study attempts to identify modifiable factors associated with poor outcome, while adjusting for baseline stroke severity, in patients receiving general anesthesia. We reviewed charts of 129 patients treated between January 2003 and September 2009. The primary outcome was the modified Rankin Score of 0-2 for 3 months poststroke. Predictors of neurologic outcome included baseline National Institutes of Health Stroke Scale score, blood glucose concentration, and age. Additional risk factors evaluated were prolonged stroke onset-treatment interval and systolic blood pressure less than 140 mmHg. Choice of local anesthesia or general anesthesia was recorded. The study group was 96 out of 129 patients for whom modified Rankin Scale scores were available; 48 patients received general anesthesia and 48 local anesthesia. The proportion of patients with "good" outcomes were 15% and 60% in the general anesthesia group and local anesthesia group, respectively (P < 0.001). Lowest systolic blood pressure and general anesthesia were correlated (r = -0.7, P < 0.001). Independent predictors for good neurologic outcome were local anesthesia, systolic blood pressure greater than 140 mmHg, and low baseline stroke scores. Adjusted for stroke severity, patients who received general anesthesia for treatment are less likely to have a good outcome than those managed with local anesthesia. This may be due to preintervention risk not included in the stroke severity measures. Hypotension, more frequent in the general anesthesia patients, may also contribute.

Cell-Free DNA as a Marker for Prediction of Brain Damage in Traumatic Brain Injury in Rats

Traumatic brain injury (TBI) is a major cause of morbidity and mortality, and early predictors of neurological outcomes are of great clinical importance. Cell free DNA (CFD), a biomarker used for the diagnosis and monitoring of several diseases, has been implicated as a possible prognostic indicator after TBI. The purpose of this study was to determine the pattern and timing of CFD levels after TBI, and whether a relationship exists between the level of CFD and brain edema and neurological outcomes. Thirty-nine Sprague-Dawley rats were randomly assigned to two groups: rats in group 1 (sham group) were anesthetized and had a scalp incision without TBI, and rats in group 2 were anesthetized and had a scalp incision with TBI, which was induced by using a weight drop model that causes diffuse brain injury. A neurological severity score (NSS) was assessed at 1, 24, and 48 h after TBI. CFD was measured via blood samples drawn at t=0 (baseline), 12, 24, 48, 72, and 120 h after TBI. At 48 h after TBI, brain edema was determined in a subgroup of 11 rats by calculating the difference between rats' wet and dry brain weight. The significance of comparisons between and within groups (CFD levels, brain water content, and NSS) were determined using the Kruskal-Wallis, Mann-Whitney and Student t test. The correlation between CFD levels and the NSS, as well as between CFD levels and the extent of brain edema, was calculated using the Spearman and Pearson tests, respectively. Compared with baseline levels, the CFD levels in rats subjected to TBI were significantly increased at 24 and 48 h after TBI (p<0.01 and p<0.05, respectively). A positive correlation was demonstrated between CFD levels 24 h following TBI and the extent of brain edema (r=0.63, p<0.05), as well as between CFD levels and the NSS (r=0.79, p<0.005). In this study, we demonstrated an increase in CFD levels after TBI, as well as a correlation between CFD levels and brain edema and NSS. CFD levels may provide a quick, reliable, and simple prognostic indicator of neurological outcome in animals after TBI. Its role in humans has not been clearly elucidated, but has potentially significant clinical implications.

Neurodevelopmental outcome in full‐term newborns with refractory neonatal seizures

This retrospective study describes the prognosis of full-term newborns with refractory neonatal seizures, comparing the need for treatment with two versus three or more antiepileptic drugs. We reviewed our database (January 2002-December 2007) to include newborns with refractory neonatal seizures and abnormal electroencephalogram. Group A consisted of 17 newborns with two antiepileptic drugs. Group B consisted of 29 newborns with three or more antiepileptic drugs. Outcome was determined at 2 years of age using the Dutch Bayley Scales of Infant Development or a neurodevelopmental classification scheme. Group A and group B were comparable regarding to a variety of demographic and aetiologic factors. Thirteen newborns died before 2 years of age and one was lost to follow-up. Normal development at 2 years of age was found in 50% and 5% for group A and B, respectively. Severe neurodevelopmental delay at 2 years of age was found in 30% and 68% for group A and B, respectively. The number of antiepileptic drugs probably reflects increased seizure burden and is--in that way--related to poor outcome. This may be useful information for early prediction of adverse neurological outcome in the first days of life.

Spreading depolarisations and outcome after traumatic brain injury: a prospective observational study

Pathological waves of spreading mass neuronal depolarisation arise repeatedly in injured, but potentially salvageable, grey matter in 50-60% of patients after traumatic brain injury (TBI). We aimed to ascertain whether spreading depolarisations are independently associated with unfavourable neurological outcome. We did a prospective, observational, multicentre study at seven neurological centres. We enrolled 109 adults who needed neurosurgery for acute TBI. Spreading depolarisations were monitored by electrocorticography during intensive care and were classified as cortical spreading depression (CSD) if they took place in spontaneously active cortex or as isoelectric spreading depolarisation (ISD) if they took place in isoelectric cortex. Investigators who treated patients and assessed outcome were masked to electrocorticographic results. Scores on the extended Glasgow outcome scale at 6 months were fitted to a multivariate model by ordinal regression. Prognostic score (based on variables at admission, as validated by the IMPACT studies) and spreading depolarisation category (none, CSD only, or at least one ISD) were assessed as outcome predictors. Six individuals were excluded because of poor-quality electrocorticography. A total of 1328 spreading depolarisations arose in 58 (56%) patients. In 38 participants, all spreading depolarisations were classified as CSD; 20 patients had at least one ISD. By multivariate analysis, both prognostic score (p=0·0009) and spreading depolarisation category (p=0·0008) were significant predictors of neurological outcome. CSD and ISD were associated with an increased risk of unfavourable outcome (common odds ratios 1·56 [95% CI 0·72-3·37] and 7·58 [2·64-21·8], respectively). Addition of depolarisation category to the regression model increased the proportion of variance in outcome that could be attributed to predictors from 9% to 22%, compared with the prognostic score alone. Spreading depolarisations were associated with unfavourable outcome, after controlling for conventional prognostic variables. The possibility that spreading depolarisations have adverse effects on the traumatically injured brain, and therefore might be a target in the treatment of TBI, deserves further research. US Army CDMRP PH/TBI research programme.

Prognostic Accuracy of Thalamic Proton Magnetic Resonance Spectroscopy Following Therapeutic Hypothermia in Neonatal Encephalopathy

Background and aims: Deep grey matter lactate/N-acetylaspartate (Lac/NAA) peak area ratio on proton magnetic resonance spectroscopy (1H MRS) is the best predictor of neurological outcome following neonatal encephalopathy (NE). We evaluated the prognostic accuracy following therapeutic hypothermia (TH).Methods: We performed magnetic resonance imaging (MRI) in consecutive term babies with NE, over a 3 year period before and after introduction of TH. Death or severe neurodisability (BSID 3) at 12 months was considered as an unfavourable outcome.Results: Of 28 babies studied, 11 babies received TH. The median (range) age at MRI was 10 (5,12) days. Thalamic Lac/NAA (>0.29) had 100% sensitivity and specificity for predicting adverse outcome in both normothermic babies and cooled infants (Table 1). The mean (SD) Lac/NAA was high in infants who had unfavorable outcome (Figure 1)Table Full size tableConclusions: The prognostic accuracy of 1H MRS deep gray matter Lac/NAA peak area ratios is unaltered by TH.

Perinatal and Early Postnatal Factors Underlying Developmental Delay and Disabilities

A delay in meeting developmental milestones may be secondary to perinatal events, involving complicated interactions between mother and fetus during delivery. Maternal factors including weight, diet, and morbidities can affect neonatal adaptation and later development. Prematurity, low birth weight, and previous intrauterine insults as well as complications during delivery of a previously normal fetus increase the risk for perinatal stress. In this article, the literature on perinatal and early postnatal factors that underlie risks for developmental delay and disabilities is reviewed. Studies that concern neuroprotective therapies and prediction of long-term neurologic outcome by clinical examination, neuroimaging techniques, and electroencephalographic studies are reviewed as well.