Severe Cerebral Edema Research Articles

Air embolism during unsuccessful transcatheter closure of secundum atrial septal defect in a patient with an undetected left-sided inferior vena cava.

A 46-year-old man with a history of secundum atrial septal defect and interstitial lung disease was admitted to the hospital for a planned transcatheter closure of the atrial septal defect. Following multiple failed attempts to place a right femoral vein catheter, the procedure was aborted. Another attempt was made to the left femoral vein, but that attempt was complicated by an unfamiliar resistance. Even though resistance was met during insertion, the catheter was further inserted until a position in the inferior vena cava above the liver was obtained at fluoroscopy. Simultaneously, the patient became unresponsive. The procedure was immediately aborted and the atrial septal defect closure was not completed. Air embolism to the heart and brain was detected using echocardiography and computed tomography. The patient died 15 days after the procedure. Death was attributed to severe cerebral edema due to air embolism. The autopsy revealed a left-sided inferior vena cava. This case report demonstrates that unexpected congenital vascular anomalies complicating a routine transcatheter closure of the atrial septal defect can result in a fatal outcome.

Application of 3D-Slicer Software in the Treatment of Gliomas.

To explore the application of 3D-Slicer multimodal image fusion technology in the surgical treatment of gliomas. A retrospective analysis of clinical data from 48 cases of intracranial gliomas treated with 3D-Slicer multimodal image fusion technology from September 2021 to February 2023. Preoperative cranial CT, MRI, TOF-MRA, DTI, and MRV sequence examinations were completed. DICOM format medical imaging data were processed using the 3D-Slicer software. Multimodal fusion and 3-dimensional reconstruction of the tumor and surrounding structures were conducted to clarify the relationship between the tumor and surrounding structures. The surgery path was simulated through 3D virtual visualization images, enabling precise preoperative planning and assisting in surgical treatment. Out of 48 patients, complete tumor resection was achieved in 45 cases. One case encountered severe postoperative cerebral edema, no infections were reported, 1 patient had slightly reduced muscle strength after surgery compared with before, and no cases of severe neurological function damage or surgical death were recorded. 3D-Slicer multimodal image fusion technology can assist in detailed preoperative planning for the surgical treatment of intracranial glioma, reducing surgical complications, improving the rate of total tumor resection, and reducing postoperative complications.

Cerebrospinal fluid markers of neuroinflammation and coagulation in severe cerebral edema and chronic hydrocephalus after subarachnoid hemorrhage: a prospective study

BackgroundEarly severe cerebral edema and chronic hydrocephalus are the primary cause of poor prognosis in patients with subarachnoid hemorrhage (SAH). This study investigated the role of cerebrospinal fluid (CSF) inflammatory cytokines and coagulation factors in the development of severe cerebral edema and chronic hydrocephalus in patients with SAH.MethodsPatients with SAH enrolled in this study were categorized into mild and severe cerebral edema groups based on the Subarachnoid Hemorrhage Early Brain Edema Score at admission. During long-term follow-up, patients were further classified into hydrocephalus and non-hydrocephalus groups. CSF samples were collected within 48 h post-SAH, and levels of inflammatory cytokines and coagulation factors were measured. Univariate and multivariate logistic regression analyses were performed to identify independent factors associated with severe cerebral edema and chronic hydrocephalus. The correlation between inflammatory cytokines and coagulation factors was further investigated and validated in a mouse model of SAH.ResultsSeventy-two patients were enrolled in the study. Factors from the extrinsic coagulation pathway and inflammatory cytokines were associated with both severe cerebral edema and chronic hydrocephalus. Coagulation products thrombin-antithrombin complexes (TAT) and fibrin, as well as inflammatory cytokines IL-1β, IL-2, IL-5, IL-7, and IL-4, were independently associated with severe cerebral edema. Additionally, Factor VII, fibrin, IL-2, IL-5, IL-12, TNF-α, and CCL-4 were independently associated with chronic hydrocephalus. A positive correlation between extrinsic coagulation factors and inflammatory cytokines was observed. In the SAH mouse model, tissue plasminogen activator was shown to alleviate neuroinflammation and cerebral edema, potentially by restoring glymphatic-meningeal lymphatic function.ConclusionsElevated levels of inflammatory cytokines and extrinsic coagulation pathway factors in the CSF are associated with the development of early severe cerebral edema and chronic hydrocephalus following SAH. These factors are interrelated and may contribute to post-SAH glymphatic-meningeal lymphatic dysfunction.

A study of clinical & radiological outcomes of small single enhancing lesions in CT brain - in a tertiary care hospital

Introduction Small single enhancing lesion in CT (SSECT) scan as an entity came into existence in India in early 1980, with the advent of CT scan. Tandon et al3 labeled them as intracranial tuberculomas. They identified two types of lesions based on the appearance of the lesion in the C T Scan brain. Small ring and disc lesions were called as immature tuberculomas and large lobulated lesions were called as mature tuberculomas. ATT was invariably started in these patients. Sethi et al5 & Bansal et al6 noted that these lesions disappeared spontaneously without treatment. Natarajan and Arjundas et al37 at the Institute of Neurology, Chennai also noted spontaneous disappearance of these lesions without specific treatment. The exact cause of these lesions could not be deciphered because apart from tuberculoma, cysticercus granuloma, pyogenic abscess, metastases, fungal granuloma, and glioma had been reported to cause similar appearance in CT scan brain as more centers acquired C.T. Scan facility. Hence the exact aetiology of these lesions became a subject of speculation. A significant breakthrough came in 1987 at Vellore 8 when stereo tactic biopsy was done on 15 patients with SSECT. Most of the lesions were identified as cysticercus and none were of tuberculous etiology. Bhargava and Tandon in 1988 and Wadia, Makhalle in 19863,4, found evidence of tuberculous lesions in histopathology. However they failed in defining the size of the lesion. Rajshekhar et al8 then defined a small single lesion based on CT appearance as “A solitary, contrast-enhancing lesion of less than 20- mm diameter lesion without severe cerebral edema (no midline shift)”.this definition is often equated to cysticercous granuloma but there is every possibility that these lesions could be a tuberculoma.

Managing medically refractory elevated intracranial pressure in a pediatric patient on ECMO: illustrative case.

We demonstrate the complexities of managing pediatric patients on extracorporeal membrane oxygenation (ECMO) therapy requiring neurosurgery, focusing on systemic anticoagulation, cardiac function, and medically refractory intracranial pressure (ICP). A 3.5-year-old female with Tetralogy of Fallot developed severe ischemic cerebral edema following post-operative cardiac arrest and required ECMO. This case, along with four additional cases of children requiring neurosurgery while on ECMO, was examined. Emergency neurosurgical intervention in the primary case led to significant improvement, highlighting the delicate balance between managing ECMO-induced anticoagulation and urgent neurosurgical needs. The additional cases had variable outcomes, emphasizing the challenges of caring for these critically ill patients. Successful management of children requiring ECMO support and neurosurgical intervention requires thoughtful multidisciplinary care. This report illustrates some of the nuances in such decision-making, and demonstrates one potential path to a good outcome.

The Silent Threat: Unraveling the Rare Catastrophic Complication after Elective Cranioplasty

AbstractAlthough cranioplasty seems to be a simple procedure, fatal complication of development of diffuse severe cerebral edema following cranioplasty although unusual have been reported in a few cases. The mechanism for this occurrence is still speculative. A 38-year-old male patient presented with a history of having undergone left decompressive hemicraniectomy following a road traffic accident with traumatic left intracranial internal carotid artery dissection leading to anterior cerebral artery and middle cerebral artery territory infarct and endovascular embolization of traumatic type 1 left caroticocavernous fistula. The preoperative computed tomography scan of the brain revealed left frontotemperoparietal craniectomy defect with sunken flap and diffuse encephalomalacia with gliosis of the entire left cerebral hemisphere. Immediately following an uneventful cranioplasty surgery with titanium mesh, the patient developed severe hypotension and dilated fixed pupils. Postoperative imaging revealed diffuse severe cerebral edema in bilateral hemispheres with a significant midline shift toward the ipsilateral (left) side, that is, toward the side of cranioplasty. The patient immediately underwent removal of the titanium mesh, and despite all efforts, the patient had a fatal outcome on postoperative day 5. Although this type of fatal complication of diffuse severe cerebral edema is rare in postcranioplasty patients, neurosurgeons must be aware of this complication and close monitoring postprocedure is important, especially in patients with a large craniectomy defect and sunken skin flap.

Quadriparesis and paraparesis following chimeric antigen receptor T-cell therapy in children and adolescents

AbstractImmune effector cell–associated neurotoxicity syndrome (ICANS) is a common but potentially severe adverse event associated with chimeric antigen receptor T-cell (CART) therapy, characterized by the development of acute neurologic symptoms following CART infusion. ICANS encompasses a wide clinical spectrum typified by mild to severe encephalopathy, seizures, and/or cerebral edema. As more patients have been treated with CART, new ICANS phenomenology has emerged. We present the clinical course of 5 children who developed acute onset of quadriparesis or paraparesis associated with abnormal brain and/or spine neuroimaging after infusion of CD19- or CD22-directed CART, adverse events not previously reported in children. Orthogonal data from autopsy studies, cerebrospinal fluid (CSF) flow cytometry, and CSF proteomics/cytokine profiling demonstrated chronic white matter destruction, but a notable lack of inflammatory pathologic changes and cell populations. Instead, children with quadriparesis or paraparesis post-CART therapy had lower levels of proinflammatory cytokines, such as interferon gamma, CCL17, CCL23, and CXCL10, than those who did not develop quadriparesis or paraparesis. Taken together, these findings imply a noninflammatory source of this newly described ICANS phenomenon in children. The pathophysiology of some neurologic symptoms following CART may therefore have a more complex etiology than exclusive T-cell activation and excessive cytokine production.

Emergent Management of Central Nervous System Demyelinating Disorders.

This article reviews the various conditions that can present with acute and severe central nervous system demyelination, the broad differential diagnosis of these conditions, the most appropriate diagnostic workup, and the acute treatment regimens to be administered to help achieve the best possible patient outcomes. The discovery of anti-aquaporin 4 (AQP4) antibodies and anti-myelin oligodendrocyte glycoprotein (MOG) antibodies in the past two decades has revolutionized our understanding of acute demyelinating disorders, their evaluation, and their management. Demyelinating disorders comprise a large category of neurologic disorders seen by practicing neurologists. In the majority of cases, patients with these conditions do not require care in an intensive care unit. However, certain disorders may cause severe demyelination that necessitates intensive care unit admission because of numerous simultaneous multifocal lesions, tumefactive lesions, or lesions in certain brain locations that lead to acute severe neurologic dysfunction. Intensive care may be necessary for the management and prevention of complications for patients who have severely altered mental status, rapidly progressive neurologic worsening, elevated intracranial pressure, severe cerebral edema, status epilepticus, or respiratory failure.

Predicting brain edema and outcomes after thrombectomy in stroke: Frontal delta/alpha ratio as an optimal quantitative EEG index

ObjectiveWe aimed to determine whether quantitative electroencephalography (QEEG) measures have predictive value for cerebral edema (CED) and clinical outcomes in acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion who underwent mechanical thrombectomy (MT). MethodsA total of 105 patients with AIS in the anterior circulation were enrolled in this prospective study. The occurrence and severity of CED were assessed through computed tomography conducted 24 h after MT. Clinical outcomes were evaluated based on early neurological deterioration (END) and 3-month functional status, as measured by the modified Rankin scale (mRS). Electroencephalography (EEG) recordings were performed 24 h after MT, and QEEG indices were calculated from the standard 16 electrodes and 2 frontal channels (F3-C3, F4-C4). The delta/alpha ratio (DAR), the (delta + theta) / (alpha + beta) ratio (DTABR), and relative delta power were averaged over all electrodes (global) and the F3-C3 and F4-C4 channels (frontal). The predictive effect and value of QEEG indices for CED and clinical outcomes were assessed using ordinal and logistic regression models, as well as receiver operating characteristic (ROC) curves. ResultsSignificantly, both global and frontal DAR were found to be associated with the severity of CED, END, and poor functional outcomes at 90 days, while global and frontal DTABR and relative delta power were not associated with outcomes. In ROC analysis, the best predictive effect was observed in frontal DAR, with an area under the curve of approximately 0.80. It exhibited approximately 75% sensitivity and 71% specificity for radiological and clinical outcomes when a threshold of 3.3 was used. ConclusionsQEEG techniques may be considered an efficient bedside monitoring method for assessing treatment efficacy, identifying patients at higher risk of severe CED and END, and predicting long-term functional outcomes. SignificanceQEEG can help identify patients at risk of severe neurological complications that can impact long-term functional recovery in AIS patients who underwent MT.

Hemorrhage Volume Drives Early Brain Injury and Outcome in Poor-Grade Aneurysmal SAH.

Early brain injury is a major determinant of clinical outcome in poor-grade (World Federation of Neurosurgical Societies [WFNS] IV-V) aneurysmal SAH and is radiologically defined by global cerebral edema. Little is known, though, about the effect of global intracranial hemorrhage volume on early brain injury development and clinical outcome. Data from the multicentric prospective Poor-Grade Aneurysmal Subarachnoid Hemorrhage (POGASH) Registry of consecutive patients with poor-grade aneurysmal SAH admitted from January 1, 2015, to August 31, 2022, was retrospectively evaluated. Poor grade was defined according to the worst-pretreatment WFNS grade. Global intracranial hemorrhage volume as well as the volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH were calculated by means of analytic software in a semiautomated setting. Outcomes included severe global cerebral edema (defined by Subarachnoid Hemorrhage Early Brain Edema Score grades 3-4), in-hospital mortality (mRS 6), and functional independence (mRS 0-2) at follow-up. Among 400 patients (median global intracranial hemorrhage volume of 91 mL; interquartile range, 59-128), severe global cerebral edema was detected in 218/400 (54.5%) patients. One hundred twenty-three (30.8%) patients died during the acute phase of hospitalization. One hundred fifty-five (38.8%) patients achieved mRS 0-2 at a median of 13 (interquartile range, 3-26) months of follow-up. Multivariable analyses showed global intracranial hemorrhage volume as independently associated with severe global cerebral edema (adjusted OR, 1.009; 95% CI, 1.004-1.014; P < .001), mortality (adjusted OR, 1.006; 95% CI, 1.001-1.01; P = .018) and worse clinical outcome (adjusted OR, 0.992; 95% CI, 0.98-0.996; P < .010). The effect of global intracranial hemorrhage volume on clinical-radiologic outcomes changed significantly according to different age groups (younger than 50, 50-70, older than 70 year of age). Volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH affected the 3 predefined outcomes differently. Intracerebral hemorrhage volume independently predicted global cerebral edema and long-term outcome, intraventricular hemorrhage volume predicted mortality and long-term outcome, and SAH volume predicted long-term clinical outcome. Global intracranial hemorrhage volume plays a pivotal role in global cerebral edema development and emerged as an independent predictor of both mortality and long-term clinical outcome. Aging emerged as a reducing predictor in the relationship between global intracranial hemorrhage volume and global cerebral edema.

Central Neurocytoma in a Teenager, a Rare Cause of Hemiplegia, and a Diagnostic Dilemma in a Resource-Poor Setting

Background. Central neurocytoma is a benign intraventricular neuroectodermal tumor most often arising in the lateral ventricles. Due to the location of this tumor, common signs and symptoms include obstructive hydrocephalus, recurrent headache, visual impairment, nausea, and vomiting. Central neurocytoma and intraventricular oligodendroglioma share similar gross features and cellular and architectural morphology, which may pose a diagnostic challenge in a poor resource setting. Immunohistochemical neuronal stains are useful for the two tumors in our setting. Report. An 18-year-old male patient presented with a 1-year history of right-sided weakness, recurrent seizures, and sudden loss of consciousness. The patient showed signs of increased intracranial pressure, but an antemortem CT or MRI scan could not be done to determine the underlying cause, due to lack of availability and poor prognosis of the patient at the time of presentation. An autopsy revealed a well-demarcated solid cystic, gritty intraventricular tumor causing obstructive hydrocephalus, with associated dilated ventricles and severe cerebral edema. Postmortem histopathological examination of the tumor confirmed central neurocytoma. Conclusion. Central neurocytoma (CN) is an uncommon cause of intracranial space occupying lesion (ICSOL) in the teenage age group in our setting. Central neurocytoma and intraventricular oligodendroglioma share similar radiologic and histomorphological features. Immunohistochemical evaluation with neuronal markers is essential in these two tumors, as they have different prognoses and surgical and treatment outcomes.

Automatic segmentation of hemispheric CSF on MRI using deep learning: Quantifying cerebral edema following large hemispheric infarction

Background and objectiveCerebral edema (CED) is a serious complication of acute ischemic stroke (AIS), especially in patients with large hemispheric infarction (LHI). Herein, a deep learning-based approach is implemented to extract CSF from T2-Weighted Imaging (T2WI) and evaluate the relationship between quantified cerebrospinal fluid and outcomes. MethodsPatients with acute LHI who underwent magnetic resonance imaging (MRI) were included. We used a deep learning algorithm to segment the CSF from T2WI. The hemispheric CSF ratio was calculated to evaluate its relationship with the degree of brain edema and prognosis in patients with LHI. ResultsFor the 93 included patients, the left and right cerebrospinal fluid regions were automatically extracted with a mean Dice similarity coefficient of 0.830. Receiver operating characteristic analysis indicated that hemispheric CSF ratio was an accurate marker for qualitative severe cerebral edema (area under receiver-operating-characteristic curve 0.867 [95% CI, 0.781–0.929]). Multivariate logistic regression analysis of functional prognosis showed that previous stroke (OR = 5.229, 95% CI 1.013–26.984), ASPECT≤6 (OR = 13.208, 95% CI 1.136–153.540) and low hemispheric CSF ratio (OR = 0.966, 95% CI 0.937–0.997) were significantly associated with higher chances for unfavorable functional outcome in patients with LHI. ConclusionsAutomated assessment of CSF volume provides an objective biomarker of cerebral edema that can be leveraged to quantify the degree of cerebral edema and confirm its predictive effect on outcomes after LHI.

Abstract TP140: Effect of MR-Guided Perfusion Imaging Mismatch Profiles Within 6 Hours on Endovascular Thrombectomy Outcomes

Background: The treatment of acute ischemic stroke (AIS) aims to achieve early vascular recanalization and reperfusion of the penumbra. However, the effect of early penumbral imaging within 6 hours on clinical outcomes remains unclear. Objective: The objective of this study was to determine the effect of magnetic resonance-guided (MR-guided) perfusion imaging within 6 hours after symptom onset on endovascular thrombectomy outcomes in AIS patients. Methods: We prospectively collected the clinical information of consecutive AIS patients undergoing endovascular thrombectomy based on MR-guided perfusion imaging within 6 hours after symptom onset from AISRNA and EVTRNA studies. The primary outcome was defined as the poor outcome (mRS &gt; 2 within 90 days). The perfusion-weighted imaging/diffusion-weighted imaging (PWI/DWI) mismatch was assessed by an automated software. Results: We enrolled 84 patients (25 in the mismatch ≤ 1.8 group and 59 in the mismatch &gt; 1.8 group). Significant difference was found between the mismatch&gt;1.8 group and the mismatch≤1.8 group for the incidence of disabling stroke (mRS &gt; 2) within 90 days (40.7% vs. 68.0%, OR: 3.099, 95% CI: 1.154-8.323, P =0.025). Intracranial hemorrhage occurred in 8 patients (13.6%) in the mismatch &gt; 1.8 group and 10 patients in the mismatch ≤ 1.8 group (40.0%) (P = 0.010). The risk of severe cerebral edema was 2/59 (3.4%) vs. 7/25 (28.0%) (P = 0.004). These findings remained stable after adjustment. Conclusion: MR-guided perfusion imaging mismatch profiles within 6 hours after symptom onset may be feasible to improve clinical outcomes and reduce clinically ineffective reperfusion after endovascular thrombectomy.

Neuron Derived Cold-Inducible RNA-Binding Protein Promotes NETs Formation to Exacerbate Brain Endothelial Barrier Disruption after Ischemic Stroke.

In ischemic stroke, neutrophils are the first-line peripheral immune cells infiltrating the brain tissue to form neutrophil extracellular traps (NETs). The present study aimed to investigate the role of neuronal cold-inducible RNA-binding protein (CIRP) in promoting NETs-induced brain endothelial barrier destruction and cerebral edema after ischemic stroke. We found that the expression of NETs and neuronal CIRP in the penumbra increased at 6 hours after transient middle cerebral artery occlusion (tMCAO) and increased significantly at 24 hours, reaching a peak at 3 days. NETs degradation or CIRP inhibition can alleviate the leakage of brain endothelial barrier and reverse the decreased expression of tight junction proteins (zonula occludens-1, claudin-5 and occludin) in tMCAO mice. Oxygen-glucose deprivation/reperfusion treated primary neurons or recombinant CIRP could induce NETs formation via TLR4/p38 signaling pathway in vitro. Transcription factor specificity protein 1 (sp1) was responsible for the increased neuronal CIRP expression and the inhibition of sp1 could suppress the increased CIRP expression, reduce NETs formation, and diminish brain endothelial barrier leakage in tMCAO mice. We also found the upregulated CIRP level was associated with severe cerebral edema in patients with acute ischemic stroke. In conclusion, the increased expression of transcription factor sp1 after ischemic stroke can lead to elevated CIRP expression and release from the neurons, which subsequently interacts with neutrophils and promotes NETs formation, resulting in brain endothelial barrier destruction and cerebral edema.

Abstract 352: Automated Deep Learning Algorithms Outperforms Gray-White Matter Ratio for the Detection of Severe Cerebral Edema in Cardiac Arrest Survivors

Introduction: Significant knowledge gaps remain in predicting neurological outcomes for comatose cardiac arrest survivors. Severe cerebral edema (SCE) development offers an objective imaging surrogate for neurologic injury. Aim: We have previously shown that deep learning (DL) algorithms can detect SCE on CT. We aim to determine whether our model will perform equivalently on an independent external cohort. We also compared the performance of the DL model with one based on the gray-white matter ratio (GWR) for detecting SCE. Method: We retrospectively analyzed CT data (299 patients, 55±17 years, 71% male, 65 with SCE). Scans whose radiology reports described herniation or more than minimal ventricular effacement were classified as SCE. Datasets were randomly split (balancing for SCE) into training, validation, and testing cohorts. We used transfer learning with a 3D residual neural network framework to train our model. The probability of SCE was calculated. We applied the model to an external cohort (151 patients, 58±17 years, 63% male, 29 with SCE). Regions of interest (ROIs) were drawn in the caudate nuclei (CN) and posterior limbs of the internal capsule (PLIC). GWR was calculated as the ratio of mean x-ray attenuation values in the CN and the PLIC. Areas under the receiver operating curves (AUC) for the DL and GWR models were compared (bootstrap test). Results: The optimal model achieved comparable accuracies for the internal validation cohort (84% [95% CI: 78-89%], n=60) and reserved test cohort (83% [95% CI: 76 to 89%], n=61). The external cohort consisted of 175 scans. The model’s accuracy was 87% [95% CI: 81% to 91%], comparable to the results from the testing and internal validation cohorts. AUC for DL was significantly greater than for GWR (92% vs. 73%, P=0.001) (see Figure). Conclusions: Our result shows that deep transfer learning is a promising method to automate SCE detection on CT images and outperforms GWR measurements.

Operative Hysteroscopy Intravascular Absorption Syndrome - A Life-Threatening Complication.

OHIA syndrome occurs due to the systemic absorption of the irrigation fluid used during hysteroscopic procedures.The presentation is diverse with encephalopathy, pulmonary oedema, dysrhythmias, electrolyte disturbances and coagulopathy.Fluid balance and irrigation fluid pressures should be monitored during hysteroscopic procedures to mitigate OHIA development.

Net water uptake within the ischemic penumbra predicts the presence of the midline shift in patients with acute ischemic stroke.

The study aimed to explore the association between midline shift (MLS) and net water uptake (NWU) within the ischemic penumbra in acute ischemic stroke patients. This was a retrospective cohort study that examined patients with anterior circulation stroke. Net water uptake within the acute ischemic core and penumbra was calculated using data from admission multimodal CT scans. The primary outcome was severe cerebral edema measured by the presence of MLS on 24 to 48 h follow-up CT scans. The presence of a significant MLS was defined by a deviation of the septum pellucidum from the midline on follow-up CT scans of at least 3 mm or greater due to the mass effect of ischemic edema. The net water uptake was compared between patients with and without MLS, followed by logistic regression analyses and receiver operating characteristics (ROCs) to assess the predictive power of net water uptake in MLS. A total of 133 patients were analyzed: 50 patients (37.6%) with MLS and 83 patients (62.4%) without. Compared to patients without MLS, patients with MLS had higher net water uptake within the core [6.8 (3.2-10.4) vs. 4.9 (2.2-8.1), P = 0.048] and higher net water uptake within the ischemic penumbra [2.9 (1.8-4.3) vs. 0.2 (-2.5-2.7), P < 0.001]. Penumbral net water uptake had higher predictive performance than net water uptake of the core in MLS [area under the curve: 0.708 vs. 0.603, p < 0.001]. Moreover, the penumbral net water uptake predicted MLS in the multivariate regression model, adjusting for age, sex, admission National Institutes of Health Stroke Scale (NIHSS), diabetes mellitus, atrial fibrillation, ischemic core volume, and poor collateral vessel status (OR = 1.165; 95% CI = 1.002-1.356; P = 0.047). No significant prediction was found for the net water uptake of the core in the multivariate regression model. Net water uptake measured acutely within the ischemic penumbra could predict severe cerebral edema at 24-48 h.

Severe diabetic ketoacidosis complicated with severe dyslipidemia, cerebral edema and acute kidney injury in a pediatric girl with type 1 diabetes mellitus: a case study

Diabetic ketoacidosis (DKA) is a life-threatening acute metabolic complication occurring in patients with type 1 diabetes, due to an insulin deficiency. Moderate hypertriglyceridemia is commonly observed in DKA but severe hypertriglyceridemia with a triglyceride level exceeding 10 g/l is very rarely reported. Acute kidney injury (AKI) is a serious condition which still carries a mortality of around 50%. Cerebral edema is a devastating complication of DKA which is leading cause of diabetes-related death in the pediatric population. Newly diagnosed diabetes, younger age, first episode of DKA, severity of DKA at presentation, and administration of bicarbonate are predictive of cerebral edema in DKA. We present a case of 8-year-old girl who presented with severe DKA, whose clinical course was complicated by renal failure, severe dyslipidemia and cerebral edema.

Reperfusion by endovascular thrombectomy and early cerebral edema in anterior circulation stroke: Results from the SITS-International Stroke Thrombectomy Registry.

A large infarct and expanding cerebral edema (CED) due to a middle cerebral artery occlusion confers a 70% mortality unless treated surgically. There is still conflicting evidence whether reperfusion is associated with a lower risk for CED in acute ischemic stroke. To investigate the association of reperfusion with development of early CED after stroke thrombectomy. From the SITS-International Stroke Thrombectomy Registry, we selected patients with occlusion of the intracranial internal carotid or middle cerebral artery (M1 or M2). Successful reperfusion was defined as mTICI ⩾ 2b. Primary outcome was moderate or severe CED, defined as focal brain swelling ⩾1/3 of the hemisphere on imaging scans at 24 h. We used regression methods while adjusting for baseline variables. Effect modification by severe early neurological deficits, as indicators of large infarct at baseline and at 24 h, were explored. In total, 4640 patients, median age 70 years and median National Institutes of Health Stroke Score (NIHSS) 16, were included. Of these, 86% had successful reperfusion. Moderate or severe CED was less frequent among patients who had reperfusion compared to patients without reperfusion: 12.5% versus 29.6%, p < 0.05, crude risk ratio (RR) 0.42 (95% confidence interval (CI): 0.37-0.49), and adjusted RR 0.50 (95% CI: 0.44-0.57). Analysis of effect modification indicated that severe neurological deficits weakened the association between reperfusion and lower risk of CED. The RR reduction was less favorable in patients with severe neurological deficits, defined as NIHSS score 15 or more at baseline and at 24 h, used as an indicator for larger infarction. In patients with large artery anterior circulation occlusion stroke who underwent thrombectomy, successful reperfusion was associated with approximately 50% lower risk for early CED. Severe neurological deficit at baseline seems to be a predictor for moderate or severe CED also in patients with successful reperfusion by thrombectomy.

Clinical Profile, Corticosteroid Usage and Predictors of Mortality in Near-hanging Patients: A Five-year, Single-center Retrospective Study.

Hanging is the most common method of suicide in India. When near-hanging patients reach the hospital for treatment, their neurological outcome ranges from full recovery to severe neurological impairment or death. This study looked at the clinical profile, usage of corticosteroids and predictors of mortality in near-hanging patients. This retrospective study was conducted from May 2017 to April 2022. Demographic, clinical, and treatment details were collected from case records. Neurological outcome at discharge was assessed using the Glasgow Outcome Scale (GOS). The study involved 323 patients, 60% of men with a median (interquartile range) age of 30 (20-39). At the time of admission, the Glasgow Coma Scale (GCS) ≤8 in 110 (34%) patients, hypotension was present in 43 (13.3%) of patients, and 21 (6.5%) had hanging-induced cardiac arrest. About 101 patients required intensive care unit care. Corticosteroid therapy was given to 219 patients (67.8%) as part of anti-cerebral edema measures. Good neurological recovery was found (GOS-5) in 84.2% of patients, and the death rate (GOS-1) was 9.3%. Univariate logistic regression showed that usage of corticosteroids is significantly associated with poor survival (p < 0.02, odds ratio 4.7). In the multivariable logistic regression analysis, GCS ≤8, hypotension, need for intensive care, hanging-induced cardiac arrest, aspiration pneumonia, and severe cerebral edema were found to be significantly associated with mortality. The majority of near-hanging patients had a good neurological recovery. Corticosteroids were used in two-thirds of the study population. There were multiple variables associated with mortality. Ramadoss R, Sekar D, Rameesh M, Saibaba J, Raman D. Clinical Profile, Corticosteroid Usage and Predictors of Mortality in Near-hanging Patients: A Five-year, Single-center Retrospective Study. Indian J Crit Care Med 2023;27(6):403-410.