Traumatic Intracerebral Hemorrhage Research Articles

Angioembolization for hemostasis in craniofacial fractures had a higher probability of delayed traumatic intracerebral hemorrhage

IntroductionWhile angioembolization is occasionally required for craniofacial fracture patients who experience massive maxillofacial hemorrhage, complications such as headache, temporal-facial pain, soft tissue necrosis, and embolic material migration leading to stroke or blindness can arise. Few studies have explored delayed or progressive intracerebral hemorrhage (ICH) following angioembolization for craniofacial fractures. MethodsA retrospective review of craniofacial fracture patients from January 1, 2015, to December 31, 2022 at our institution was conducted. We applied univariate and multivariable logistic regression (MLR) analyses to assess whether angioembolization served as an independent factor for delayed or progressive ICH. Propensity score matching (PSM) was used to balance the groups of patients who underwent angioembolization with those who did not. Outcome measurements included delayed or progressive ICH occurring within 72 hours, the need for additional neurosurgical interventions, and the length of stay (LOS) in the intensive care unit (ICU) and hospital. ResultsOf the 2,519 craniofacial fracture patients studied over an 8-year period, 21 (0.8%) underwent angioembolization for maxillofacial hemorrhage. MLR analysis revealed that angioembolization was an independent factor for delayed or progressive ICH (odds ratio=5.71, p = 0.028). After 1:2 PSM, patients who underwent angioembolization had greater rates of delayed or progressive ICH (28.6% vs. 7.1%, p = 0.023), an extended hospital LOS (17.0 vs. 15.0 days, p = 0.009) and a longer ICU LOS (10.0 vs. 4.0 days, p = 0.004). ConclusionsA greater probability of delayed or progressive ICH was observed in craniofacial fracture patients who underwent angioembolization for maxillofacial hemostasis.

Prognostic Factors of Outcome in Patients Undergoing Surgical Intervention following Traumatic Intracerebral Haemorrhage

Background: Intracerebral hemorrhage is a common complication after traumatic brain injury. While it is accepted practice to remove extra-axial (extradural and subdural) haematoma following traumatic brain injury, but surgical practice in the treatment of traumatic intracerebral hemorrhage (TICH) differs widely, and prognostic factors associated with outcome following surgery have not yet been well established. Aims: The study aimed to determine the prognostic factors of outcome in patients undergoing surgical intervention following traumatic intracerebral hemorrhage in a tertiary care hospital in southeastern part of Bangladesh. Materials and Methods: This prospective interventional study included 45 patients requiring craniotomies for decompression and evacuation of an intracranial hemorrhage following traumatic intracerebral hemorrhage in the Neurosurgery Department of Chittagong Medical College Hospital between December 2021 to June 2023. Demographic features, perioperative clinical and radiological characteristics of these patients were examined in relation to favorable/good outcome, defined as Glasgow Outcome Scale (GOS) score >3 at 3months follow-up, and unfavorable/poor outcome, defined as 3months mortality or GOS score d”3 at 3months after surgery. Results: The median age was 45 (range 8-75) years, 82.2% were male, and road traffic accident was the commonest cause (73.3%). Initial loss of consciousness was found in 75.7% of patients and the median GCS on admission was 9 (Interquartile range 8-10). Craniotomy and evacuation was done in 23(51.1%) of the cases, followed by craniectomy and evacuation in 22 (48.9%)patients. In-hospital and 3 months mortality rate was 28.9%. At three months post surgery, all of the survived patients(32) had good outcomes; 29 (92.3%) had GOS scores of 5, while the remaining 3 had GOS scores of 4. In bivariate analysis, age, history of comorbidity and loss of consciousness, GCS on admission, hematoma volume, and injury to surgery interval was found to have significant association with poor outcome (p<0.05). Age (OR: 1.211, 95% CI: 1.012-1.241, p=0.009) and GCS score on admission (OR: 0.301, 95% CI: 0.086-0.827, p=0.004) were independent predictors of 3-months poor outcome or mortality in multivariate logistic regression analysis. Conclusions: This study presented that older age(60 years) and lower GCS(7-10) on admission were the independent predictors of poor outcome after 3 months of surgery. Multicenter studies are needed to provide accurate data on traumatic intracerebral hemorrhage in Bangladesh. Bang. J Neurosurgery 2024; 13(2): 104-111

Safety, tolerability, and pharmacokinetics of antisense oligonucleotide BIIB078 in adults with C9orf72-associated amyotrophic lateral sclerosis: a phase 1, randomised, double blinded, placebo-controlled, multiple ascending dose study

Hexanucleotide repeat expansion of C9orf72 is a common genetic cause of amyotrophic lateral sclerosis (ALS). No C9orf72-targeted treatments are available. BIIB078 is an investigational antisense oligonucleotide targeting C9orf72 sense RNA. We aimed to assess the safety, tolerability, and pharmacokinetics of BIIB078 in participants with C9orf72-associated ALS. This phase 1, randomised controlled trial was done at 22 sites in six countries (Canada, Ireland, Netherlands, Switzerland, UK, and USA). Adults with ALS and a pathogenic repeat expansion in C9orf72 were randomly assigned within six cohorts, via Interactive Response Technology in a 3:1 ratio per cohort, to receive BIIB078 (5 mg, 10 mg, 20 mg, 35 mg, 60 mg, or 90 mg in cohorts 1-6, respectively) or placebo, via an intrathecal bolus injection. The treatment period consisted of three loading doses of study treatment, administered approximately once every 2 weeks, followed by monthly maintenance doses during a treatment period of about 3 months for cohorts 1-3 and about 6 months for cohorts 4-6. Patients and investigators were masked to treatment assignment. The primary endpoint was the incidence of adverse events and serious adverse events. This trial was registered with ClinicalTrials.gov (NCT03626012) and is completed. Between Sept 10, 2018, and Nov 17, 2021, 124 patients were screened for inclusion in the study. 18 patients were excluded and 106 participants were enrolled and randomly assigned to receive 5 mg (n=6), 10 mg (n=9), 20 mg (n=9), 35 mg (n=19), 60 mg (n=18), or 90 mg (n=18) of BIIB078, or placebo (n=27). 58 (55%) of 106 patients were female. All patients received at least one dose of study treatment and were included in all analyses. All participants had at least one adverse event; most adverse events were mild or moderate in severity and did not lead to treatment discontinuation. The most common adverse events in BIIB078-treated participants were falls, procedural pain, headache, and post lumbar puncture syndrome. 14 (18%) of 79 patients who received any dose of BIIB078 reported serious adverse events, compared with nine (33%) of 27 patients who received placebo. Five participants who received BIIB078 and three participants who received placebo had fatal adverse events: respiratory failure in a participant who received 10 mg BIIB078, ALS worsening in two participants who received 35 mg BIIB078, traumatic intracerebral haemorrhage in one participant who received 35 mg BIIB078, pulmonary embolism in one participant who received 60 mg BIIB078, and respiratory failure in three participants who received placebo. All deaths were assessed as not related to the study treatment by the reporting investigator. On the basis of these phase 1 study results, including secondary and exploratory findings showing no reduction in neurofilament levels and no benefit on clinical outcomes relative to the placebo cohort, BIIB078 clinical development has been discontinued. However, these results will be informative in furthering our understanding of the complex pathobiology of C9orf72-associated ALS. Biogen.

Intravenous Administration of Anti-CD47 Antibody Augments Hematoma Clearance, Mitigates Acute Neuropathology, and Improves Cognitive Function in a Rat Model of Penetrating Traumatic Brain Injury.

Traumatic brain injury (TBI)-induced intracerebral hematoma is a major driver of secondary injury pathology such as neuroinflammation, cerebral edema, neurotoxicity, and blood-brain barrier dysfunction, which contribute to neuronal loss, motor deficits, and cognitive impairment. Cluster of differentiation 47 (CD47) is an antiphagocytic cell surface protein inhibiting hematoma clearance. This study was designed to evaluate the safety and efficacy of blockade of CD47 via intravenous (i.v.) administration of anti-CD47 antibodies following penetrating ballistic-like brain injury (PBBI) with significant traumatic intracerebral hemorrhage (tICH). The pharmacokinetic (PK) profile of the anti-CD47 antibody elicited that antibody concentration decayed over 7 days post-administration. Blood tests and necropsy analysis indicated no severe adverse events following treatment. Cerebral hemoglobin levels were significantly increased after injury, however, anti-CD47 antibody administration at 0.1 mg/kg resulted in a significant reduction in cerebral hemoglobin levels at 72 h post-administration, indicating augmentation of hematoma clearance. Immunohistochemistry assessment of glial fibrillary acidic protein (GFAP) and ionized calcium-binding adaptor molecule 1 (IBA1) demonstrated a significant reduction of GFAP levels in the lesion core and peri-lesional area. Based on these analyses, the optimal dose was identified as 0.1 mg/kg. Lesion volume showed a reduction following treatment. Rotarod testing revealed significant motor deficits in all injured groups but no significant therapeutic benefits. Spatial learning performance revealed significant deficits in all injured groups, which were significantly improved by the last testing day. Anti-CD47 antibody treated rats showed significantly improved attention deficits, but not retention scores. These results provide preliminary evidence that blockade of CD47 using i.v. administration of anti-CD47 antibodies may serve as a potential therapeutic for TBI with ICH.

Neurological outcomes and mortality of hyperoxaemia in patients with acute brain injury: protocol for a systematic review and meta-analysis

IntroductionOxygen is frequently prescribed in neurocritical care units. Avoiding hypoxaemia is a key objective in patients with acute brain injury (ABI). However, several studies suggest that hyperoxaemia may also be...

Importance of Multispecialty Coordination of Care in an Electroconvulsive Therapy Patient With Musculoskeletal, Neurological, and Vascular Injuries: A Case Report.

Electroconvulsive therapy (ECT) is considered an effective therapy for patients suffering from severe, life-threatening, intractable depression. This treatment modality delivers controlled electrical currents (typically no more than 100 J) under general anesthesia to induce seizure. Although generally considered to have a high safety profile, physiological changes induced during the ictal phase of ECT, such as elevation in blood pressure and intracranial pressure, impose additional risks to patients with concomitant cardiovascular or cerebrovascular conditions. We describe the successful use of ECT in a unique case complicated by a combination of acute vertebral artery dissection, traumatic intracerebral hemorrhage, and cervical spine injury sustained from a suicide attempt by intentional motor vehicle collision. Although ECT can be safely administered in the presence of recent vertebral artery dissection and traumatic intraparenchymal hemorrhage, an emphasis on multispecialty coordination is crucial to monitor and reduce the risk of elevated blood pressure and further cervical spine injury.

Long-term survival of traumatic brain injury and intra-cerebral haemorrhage patients: A multicentric observational cohort

PurposeMortality is often assessed during ICU stay and early after, but rarely at later stage. We aimed to compare the long-term mortality between TBI and ICH patients. Materials and methodsFrom an observational cohort, we studied 580 TBI patients and 435 ICH patients, admitted from January 2013 to February 2021 in 3 ICUs and alive at 7-days post-ICU discharge. We performed a Lasso-penalized Cox survival analysis. ResultsWe estimated 7-year survival rates at 72.8% (95%CI from 67.3% to 78.7%) for ICH patients and at 84.9% (95%CI from 80.9% to 89.1%) for TBI patients: ICH patients presenting a higher mortality risk than TBI patients. Additionally, we identified variables associated with higher mortality risk (age, ICU length of stay, tracheostomy, low GCS, absence of intracranial pressure monitoring). We also observed anisocoria related with the mortality risk in the early stage after ICU stay. ConclusionsIn this ICU survivor population with a prolonged follow-up, we highlight an acute risk of death after ICU stay, which seems to last longer in ICH patients. Several variables characteristic of disease severity appeared associated with long-term mortality, raising the hypothesis that the most severe patients deserve closer follow-up after ICU stay.

Establishment and validation of a predictive model for tracheotomy in critically ill patients and analysis of the impact of different tracheotomy timing on patient prognosis

BackgroundIn critically ill patients receiving invasive mechanical ventilation (IMV), it is unable to determine early which patients require tracheotomy and whether early tracheotomy is beneficial.MethodsClinical data of patients who were first admitted to the ICU and underwent invasive ventilation for more than 24 h in the Medical Information Marketplace in Intensive Care (MIMIC)-IV database were retrospectively collected. Patients were categorized into successful extubation and tracheotomy groups according to whether they were subsequently successfully extubated or underwent tracheotomy. The patients were randomly divided into model training set and validation set in a ratio of 7:3. Constructing predictive models and evaluating and validating the models. The tracheotomized patients were divided into the early tracheotomy group (< = 7 days) and the late tracheotomy group (> 7 days), and the prognosis of the two groups was analyzed.ResultsA total of 7 key variables were screened: Glasgow coma scale (GCS) score, pneumonia, traumatic intracerebral hemorrhage, hemorrhagic stroke, left and right pupil responses to light, and parenteral nutrition. The area under the receiver operator characteristic (ROC) curve of the prediction model constructed through these seven variables was 0.897 (95% CI: 0.876–0.919), and 0.896 (95% CI: 0.866–0.926) for the training and validation sets, respectively. Patients in the early tracheotomy group had a shorter length of hospital stay, IMV duration, and sedation duration compared to the late tracheotomy group (p < 0.05), but there was no statistically significant difference in survival outcomes between the two groups.ConclusionThe prediction model constructed and validated based on the MIMIC-IV database can accurately predict the outcome of tracheotomy in critically ill patients. Meanwhile, early tracheotomy in critically ill patients does not improve survival outcomes but has potential advantages in shortening the duration of hospitalization, IMV, and sedation.

Friedman's Gradient-Boosting Algorithm Predicts Lactate-Pyruvate Ratio Trends in Cases of Intracerebral Hemorrhages

ObjectiveThe local effects of an intracerebral hemorrhage (ICH) on surrounding brain tissue can be detected bedside using multimodal brain monitoring techniques. The aim of this study is to design a gradient boosting regression model using the R package boostmtree with the ability to predict lactate-pyruvate (L/P) ratio measurements in ICH. MethodsWe performed a retrospective analysis of 6 spontaneous ICH (sICH) and 6 traumatic ICH (tICH) patients who underwent surgical removal of the clot with microdialysis catheters placed in the perihematomal zone. Predictors of glucose, lactate, pyruvate, age, sex, diagnosis, and operation status were used to design our model. ResultsIn a holdout analysis, the model forecasted L/P ratio trends in a representative in-sample testing set. We anticipate that boostmtree could be applied to designs of similar regression models to analyze trends in other MM features across other types of acute brain injury. ConclusionThe model successfully predicted hourly L/P ratios in sICH and tICH cases after the hemorrhage evacuation and displayed significantly better performance than linear models. Our results suggest that boostmtree may be a powerful tool in developing more advanced mathematical models to assess other MM parameters for cases in which the perihematomal environment is monitored.

Ruxolitinib, IV Immunoglobulin, and High-Dose Glucocorticoids for Critically Ill Adults With Secondary Hemophagocytic Lymphohistiocytosis: A Single-Center Observational Pilot Study.

Secondary hemophagocytic lymphohistiocytosis (sHLH) is a cytokine-driven inflammatory syndrome that is associated with substantial morbidity and mortality and frequently leads to ICU admission. Overall survival in adults with sHLH remains poor, especially in those requiring intensive care. Classical chemotherapeutic treatment exhibits myelosuppression and toxicity. Recently, inhibition of Janus kinase signaling by ruxolitinib has shown efficacy in pediatric HLH. We therefore aimed to determine the activity and safety of a ruxolitinib-based regimen, in critically ill adults with sHLH. Observational pilot study. Single-center tertiary academic ICU. Nine adults (≥ 18 yr) who fulfilled at least five of the eight HLH-2004 criteria. Triplet regimen combining: 1) ruxolitinib, 2) polyvalent human IV immunoglobulins (IVIG) at a dose of 1 g/kg bodyweight for 5 days, and 3) high-dose corticosteroids (CSs, dexamethasone 10 mg/m² body surface area, or methylprednisolone equivalent) with subsequent tapering according to the HLH-2004 protocol. Nine patients (median age: 42 yr [25th-75th percentile: 32-54]; male: n = 6 males, median H-score: 299 [255-304]) were treated with the triplet regimen. The median Sequential Organ Failure Assessment score at HLH diagnosis was 9 (median; 25th-75th percentile: 7-12), indicating multiple-organ dysfunction in all patients. Within 10 days a significant decrease of the inflammatory parameters soluble interleukin-2 receptor and ferritin as well as a stabilization of the blood count could be shown. All patients were alive at ICU discharge (100% ICU survival), 1 patient died after ICU discharge because of traumatic intracerebral hemorrhage that might be related to HLH or treatment, corresponding to an overall survival of 86% in a 6 months follow-up period. In this small case series, a triplet regimen of ruxolitinib in combination with IVIG and CS was highly effective and save for treating critically ill adults with sHLH.

Spectrum of Intracerebral Hemorrhage in a Tertiary Hospital

Introduction: Intracerebral hemorrhage is a devastating type of stroke that leads to profound morbidity and carries high mortality. Survivors of hemorrhagic stroke suffer not only from physical and social decline but also results in loss of productivity and financial burden.&#x0D; Causes of hemorrhagic stroke are hypertension, coagulopathic condition, diabetes mellitus and cardiovascular diseases. lesional hemorrhagic stroke can be due to subarachnoid hemorrhage from intracranial aneurysm, arteriovenous malformation, dural arteriovenous fistula etc.&#x0D; Methods: A retrospective cross sectional study carried out at KISTMCTH. Data from six years duration was analysed from hospital records, outpatient department records. Patients that presented with intracranial hemorrhage were included. Post operative patients and traumatic intracerebral hemorrhage cases were not included.&#x0D; &#x0D; Results: Total of 112 patients was included in the study. 73 (65.1%) of them were male and 39 (34.8%) were female. putamen and caudate region were most common 47 (41.9%) followed by subarachnoid region 27 (24.1%), thalamus 19 (16.9%), cerebellum 9 (8.04%) , lobar region 8 (7.1%) and brainstem 2 (1.7%). Intracranial hemorrhage was more common in age group of 41-60 years 59 (52.6%) followed by age group 61- 100 years 42 (37.5%). 14 (51.8%) female had subarachnoid hemorrage in comparision to 13 male (48.1%). Anterior communicating artery aneurysm had highest occurrence 10 (37%) followed by middle cerebral artery aneurysm 6 (22.2%) , paraclinnoidal / anterior choroidal/posterior communicating artery aneurysm 5 (18.5%), vertebral artery aneurysm 3 (11.1%), distal anterior cerebral artery aneurysm 1 (3.7%).&#x0D; Intracranial hemorrhage had highest occurrence on the month of January (15%) and lowest on the month of November (3.57%). 29 (25.8%) of total intracranial hemorrhage patient had intraventricular extension of hemorrhage. Intraventricular extension was more common in thalamic hematoma 15 (13.39%) followed by caudate/putaminal hematoma 10 (8.9%), cerebellum 3 (2.6%).Modified Rankin Scale ( MRS) outcome score was found to be highest as MRS 6 for 34 (30.6%) patients . while good outcome in terms of MRS 1 , MRS 2 and MRS 3 were observed for 7 (6.2%), 26 (23.2%), 25 (22.3%) patients respectively.&#x0D; Conclusion: Hypertension remains one of the major risk factor that results in various location specific hemorrhage and it shows specific peak seasonal variation. Proper blood pressure control is recommended for prevention of intracranial hemorrhages.

32 Pediatric traumatic brain injury and the interruption of premorbid hallucinations: a case study

Objective:Research has shown that a small, yet significant minority of individuals with traumatic brain injuries (TBI) experience psychotic symptoms post-TBI. TBI has also been associated with earlier onset schizophrenia in individuals with a genetic risk for psychosis.The current case presents a 15-year-old female with pre-existing psychotic symptoms (auditory and visual hallucinations [AVH] and delusions) who stopped experiencing AVH a few weeks post-injury. The, at least temporary, cessation of her hallucinations raises several important questions about the neuroanatomy of pediatric psychosis and the impact of TBI on a potentially divergently developing brain.Participants and Methods:Patient is a 15-year-old female who identifies as Hispanic (adopted, of Central American origin). Prior to her injury her developmental history was notable probable neglect prior to adoption, and her psychiatric history was notable for major depressive disorder, anxiety, chronic insomnia, and AVH. AVH were religious in nature and involved command hallucinations. AVH had been attributed to her chronic insomnia, per medical records. Participant was in a motorcycle accident with her caregiver and sustained a severe traumatic brain injury (GCS=3-8). Medical workup, including MRI, indicated a right basal ganglia hemorrhage, right thalamic hemorrhage, as well as injury of the brain stem at the pons, resulting in left-sided hemiparesis. She was ultimately diagnosed with traumatic right-sided intracerebral hemorrhage, traumatic subdural hematoma, traumatic hemorrhage of basal ganglia, traumatic encephalopathy, and a left homonymous hemianopia (left visual field cut) from her right temporal parietal injury. She received a neuropsychological evaluation 10 months post-TBI. Testing included: subtests of the WISC-V, measures of sustained attention and executive functioning, tasks of orientation and memory, and questionnaire measures assessing social-emotional, executive, and adaptive functioning. Parent and adolescent clinical interviews were conducted.Results:Results indicated appropriate orientation, broadly intact intelligence presumed consistent with premorbid functioning, average sustained attention, and deficits in aspects executive functioning, visual-motor processing speed, and fine motor skills. Although she performed well on objective measures of memory, she reported significant long term social memory loss (e.g., difficulties remembering friends and memories of emotional connectedness) during the clinical interview. Interview and questionnaire measures also indicated continued challenges with depression and anxiety, as well as post-traumatic personality changes, tics, and symptoms of trauma. Patient reported that her hallucinations, both visual and auditory, stopped early in her recovery post-TBI; patient’s premorbid delusions were still present post-TBI.Conclusions:This case raises questions related to the impact of structural or axonal injury to regions or networks in the brain that may be associated with psychosis. It also adds to a minimal literature examining AVH in pediatric TBI. Using the current literature as a framework we will explore 1) the injury to this patient’s thalamus as it relates to both her emotional memory deficits as well as the interruption of her AVH hallucinations, and 2) the relationship between her visual field cut and the interruption of her visual hallucinations. Overall, this case study highlights the unique nature of the developing brain both in terms of the TBI and psychosis.

A National Survey on Coma Epidemiology, Evaluation, and Therapy in India: Revisiting the Curing Coma Campaign Come Together Survey.

The limited representation from developing countries in the original COME TOGETHER survey gave us an impetus to conduct this survey in the Indian subcontinent. This cross-sectional online survey was conducted from August through September 2022. Participants were health care physicians caring for patients with coma and disorders of consciousness. Fischer's exact test or the Mann-Whitney U-test was used to compare respondents who agreed or disagreed with the preestablished coma definition. Fleiss κ values were calculated to assess agreement among respondents. A p value less than 0.05 was considered statistically significant. The survey was completed by 130 physicians. We found substantial interrater agreement on absence of wakefulness (71.54%; κ = 0.71), Glasgow Coma Score ≤ 8 (78.46%; κ = 0.78), and failure to respond purposefully to visual, verbal, or tactile stimuli (66.15%; κ = 0.66). Reported common etiologies of coma included traumatic brain injury (50.76%), ischemic stroke (30%), and intracerebral hemorrhage (29.23%). The most common clinical assessment tools used for coma included the Glasgow Coma Score (92.3%) and neurological examination (60.8%). Neurological examination was the most commondiagnostic tool used(100%), followed by magnetic resonance imaging (89.2%), basic laboratory studies (88.5%), and head computed tomography/angiography (86.9%). Pharmacological interventions used to stimulate arousal in patients with coma were sedation vacation (91.5%), electrolyte/endocrine correction (65.4%), osmotic therapy with mannitol (60%), hypertonic saline (54.6%), modafinil (46.9%), and antidote for drugs (45.4%). Among the nonpharmacological interventions, sensory stimulation (57.7%) was the most commonly used modality. The most common discharge disposition for comatose patients who survived hospitalization were home with or without services (70.0%). Differences from the global survey were noted regarding the following: traumatic brain injury being the most common etiology of coma in India, more frequent practice of sedation interruption, less frequent use of electroencephalography in India, rare use of pharmacological neurostimulants, and home being the most common discharge disposition in India.

Early enteral nutrition intervention promotes multiple functional recovery in patients with traumatic intracerebral hemorrhage: A prospective randomized controlled study

ObjectiveTo delve into how early enteral nutrition intervention exert its part in promoting multiple functional recovery in patients with traumatic intracerebral hemorrhage (TICH). MethodThis prospective randomized controlled study recruited 152 traumatic intracerebral hemorrhage patients in our hospital. The observation group (n = 77) received early enteral nutrition intervention (≤ 48 h), while the control group (n = 75) were given delayed enteral nutrition (> 48 h). Further comparison was performed on the recovery of various physiologic functions between the two groups. ResultsAfter treatment, GCS score and GOS score in the observation group were significantly higher than those in the control group (P < 0.05), and mRS Score was significantly lower than that in the control group (P < 0.05). Moreover, the observation group demonstrated a considerable post-treatment elevation in adrenocorticotropic hormone (ACTH) and cortisol (Cor) levels, which were notably higher than the control group's levels (both P < 0.05). The changes in Bifidobacteria, Enterococcus, and Escherichia coli values pre and post-treatment were more remarkable in the observation group (all P < 0.05). Kaplan-Meier survival curve analysis indicated a substantial difference in survival curves between patients who provided with early enteral nutrition and those where it later (P < 0.05). ConclusionThe early application of enteral nutrition can promote neurological function recovery, improve the disorder of intestinal flora and the patient's nutritional status, reduce the increase of injury factors under stress, and lower the mortality risk among patients suffering from TICH.

EAAT3 impedes oligodendrocyte remyelination in chronic cerebral hypoperfusion-induced white matter injury.

Chronic cerebral hypoperfusion-induced demyelination causes progressive white matter injury, although the pathogenic pathways are unknown. The Single Cell Portal and PanglaoDB databases were used to analyze single-cell RNA sequencing experiments to determine the pattern of EAAT3 expression in CNS cells. Immunofluorescence (IF) was used to detect EAAT3 expression in oligodendrocytes and oligodendrocyte progenitor cells (OPCs). EAAT3 levels in mouse brains were measured using a western blot at various phases of development, as well as in traumatic brain injury (TBI) and intracerebral hemorrhage (ICH) mouse models. The mouse bilateral carotid artery stenosis (BCAS) model was used to create white matter injury. IF, Luxol Fast Blue staining, and electron microscopy were used to investigate the effect of remyelination. 5-Ethynyl-2-Deoxy Uridine staining, transwell chamber assays, and IF were used to examine the effects of OPCs' proliferation, migration, and differentiation in vivo and in vitro. The novel object recognition test, the Y-maze test, the rotarod test, and the grid walking test were used to examine the impact of behavioral modifications. A considerable amount of EAAT3 was expressed in OPCs and mature oligodendrocytes, according to single-cell RNA sequencing data. During multiple critical phases of mouse brain development, there were no substantial changes in EAAT3 levels in the hippocampus, cerebral cortex, or white matter. Furthermore, neither the TBI nor ICH models significantly affected the levels of EAAT3 in the aforementioned brain areas. The chronic white matter injury caused by BCAS, on the other hand, resulted in a strikingly high level of EAAT3 expression in the oligodendroglia and white matter. Correspondingly, blocking EAAT3 assisted in the recovery of cognitive and motor impairment as well as the restoration of cerebral blood flow following BCAS. Furthermore, EAAT3 suppression was connected to improved OPCs' survival and proliferation in vivo as well as faster OPCs' proliferation, migration, and differentiation in vitro. Furthermore, this study revealed that the mTOR pathway is implicated in EAAT3-mediated remyelination. Our findings provide the first evidence that abnormally high levels of oligodendroglial EAAT3 in chronic cerebral hypoperfusion impair OPCs' pro-remyelination actions, hence impeding white matter repair and functional recovery. EAAT3 inhibitors could be useful in the treatment of ischemia demyelination.

Behavioral Effects of Repetitive Transcranial Magnetic Stimulation in Disorders of Consciousness: A Systematic Review and Meta-Analysis.

Traumatic brain injury, cardiac arrest, intracerebral hemorrhage, and ischemic stroke may cause disorders of consciousness (DoC). Repetitive transcranial magnetic stimulation (rTMS) has been used to promote the recovery of disorders of consciousness (DoC) patients. In this meta-analysis, we examined whether rTMS can relieve DoC patient symptoms. We searched through journal articles indexed in PubMed, the Web of Science, Embase, Scopus, and the Cochrane Library until 20 April 2023. We assessed whether studies used rTMS as an intervention and reported the pre- and post-rTMS coma recovery scale-revised (CRS-R) scores. A total of 207 patients from seven trials were included. rTMS significantly improved the recovery degree of patients; the weighted mean difference (WMD) of the change in the CRS-R score was 1.89 (95% confidence interval (CI): 1.39-2.39; p < 0.00001) in comparison with controls. The subgroup analysis showed a significant improvement in CRS-R scores in rTMS over the dorsolateral prefrontal cortex (WMD = 2.24; 95% CI: 1.55-2.92; p < 0.00001; I2 = 31%) and the primary motor cortex (WMD = 1.63; 95% CI: 0.69-2.57; p = 0.0007; I2 = 14%). Twenty-hertz rTMS significantly improved CRS-R scores in patients with DoC (WMD = 1.61; 95% CI: 0.39-2.83; p = 0.010; I2 = 31%). Furthermore, CRS-R scores in rTMS over 20 sessions significantly improved (WMD = 1.75; 95% CI: 0.95-2.55; p < 0.0001; I2 = 12%). rTMS improved the symptoms of DoC patients; however, the available evidence remains limited and inadequate.

Intraoperative Anesthetic Management of Bilateral Intraventricular Hemorrhage Secondary to Anterior Communicating Artery Aneurysm Rupture in Hypertensive Patient

Introduction: Primary (IVH) is non traumatic intracerebral hemorrhage confined to the ventricular system which is relatively infrequent, but is more commonly caused by hypertensive (52%) hemorrhagic stroke, followed by trauma (15%), intraventricular arteriovenous malformation (7.5%), coagulopathy (7.5%), diabetic vasculopathy (7.5%), anterior communicating artery aneurysms (3%), and undetectable cause. Clipping of ruptured anterior communicating artery with hypertension possess anesthetic challenges in managing intra-operatively, and when it comes for an ideal neuroprotective agent, barbiturates induced anesthesia was planned. Case Report: A 70 years old male came to our hospital with history of sudden loss of consciousness and a known case of systemic hypertension for 3 years and was on irregular medications, intubated in emergency medicine department in view of low GCS which was difficult intubation. CT brain Angiogram was done and diagnosed as ruptured Anterior Communicating Artery Aneurysm and underwent Aneurysmal clipping of anterior communicating artery aneurysm under general anesthesia. Emergency medications were kept ready. Intensive neuro monitoring, invasive blood pressure monitoring and to decrease the intraoperative intracranial pressure, to preserve autoregulation of cerebral blood flow, barbiturates induced anesthesia were planned (thiopentone as an induction agent and maintained with inhalational anesthetic agent). Patient was shifted to ICU for observation and extubated on next day uneventfully. Conclusion: We present a successful anesthetic management of hypertensive patient with ruptured anterior communicating artery who underwent clipping of aneurysm. A detailed pre-anesthetic evaluation and proper planning is utmost important to encounter the risk of ischemic injury to brain while clipping of ruptured aneurysmal vessel.

221 A one-year audit of intracranial haemorrhages that presented to a level 4 hospital and died within 30 days

Abstract Background Spontaneous Intra-Cerebral Haemorrhage (ICH) constitutes 15% of all strokes and has a 1 month mortality of 40%. Different prognostic models are used but the most widely used model is the ICH score. Predictors for 30-day mortality include greater ICH volume, infratentorial location of ICH, low Glasgow Coma Scale (GCS), older age, and intraventricular extension. We audited all non-traumatic ICH that presented to a level 4 Hospital and died within 30 days in 2021. Methods We retrospectively collected all adult patients with imaging-confirmed (CT- or MRI-scan) non-traumatic ICH and died within 30 days. Patients were identified via FAST Call register. Exclusion criteria were traumatic ICH or non-parenchymal haemorrhage, haemorrhagic transformation of ischemic stroke, brain tumour associated haemorrhage. Data included age, GCS on admission, co-morbidities, Modified Rankin Score (MRS) pre admission, oral anticoagulation/anti-platelet use/time, patient’s blood pressure recordings. If the patient was referred to Neurosurgery, advice was collated. Haemorrhagic properties were measured on CT: supra- or infratentorial, intraventricular extension, and ICH volume (ABC/2 method). ICH Scores were calculated. Results 29 ICH were identified with a 30 day mortality of 37.9%(11/29) and a mean age of 80.9 years. Median-MRS pre-admission was 3, GCS on arrival was 9(3–13). 5/11(45%) were admitted to the Stroke Unit. 5 patients were on anticoagulation and 3 received a reversal agent. 8 patients had a systolic BP 150-220 mmHg on arrival of whom 3/8(38%) achieved a target BP of ≤140 mmHg at 2 hours of diagnosis. Mean volume of ICH was 45.6mls. Median ICH score was 3. Conclusion 29 patients presented with an ICH with a 30 day mortality of 37.9%. These were frail and multi-morbid patients. 45% were admitted to the stroke unit and 38% achieved optimal blood pressure control within 2 hours. This highlight two areas that could be improved to ensure optimum patient care.

Outcomes In Patients with Traumatic Acute Subdural Hematoma with Non-Convulsive Status Epilepticus (N3.002)

<h3>Objective:</h3> To evaluate the factors contributing to poor outcomes in patients with acute traumatic subdural hematoma (aSDH) who developed nonconvulsive status epilepticus (NCSE). <h3>Background:</h3> NCSE in patients with aSDH is an underdiagnosed yet fatal complication that requires prompt diagnosis and treatment. A high degree of clinical suspicion and evaluation with continuous EEG is required for prompt diagnosis and treatment. <h3>Design/Methods:</h3> This is a single-institution retrospective study approved by the local IRB. Patients with traumatic brain injury (TBI) with aSDH diagnosed with status epilepticus between the years 2016–2020 were included. Demographic, clinical, imaging, treatment, and EEG details were reviewed and collected in a HIPPA-compliant format. Logistic regression analysis was used to evaluate factors contributing to poor outcomes. <h3>Results:</h3> Out of a total of 540 patients, who had presented with traumatic acute intra-cerebral hemorrhage between the years 2016–2022, 28 patients with traumatic aSDH who had presented with status epileptics during the same hospitalization were included in the present study. NCSE was the most common form of status epilepticus (27/28). The mean age was 67 (range 20–92) years and 17(60%) were male. 12(48%) of the patients had an initial presenting GCS of 7 or less. The mean length of stay in the hospital was 16 (5–44) days. Overall mortality was 19(64%). Logistic regression analysis identified the presence of central spikes on EEG (p:0.43, OR:12.72; 95% CI 1.083–149.35) and thickness of aSDH&gt; 1cm (p: 0.025; OR: 16.545; 95%CI: 1.426–191.95) as predictors of mortality in both univariate and multivariate analysis. Good functional outcomes with mRS&lt;2 were seen in rarely 10(35%) of these patients. <h3>Conclusions:</h3> Nonconvulsive status epilepticus (NCSE) is a common form of presentation of status epilepticus in patients with acute traumatic SDH. The presence of epileptiform activity in the central leads in EEG often leads to resistant seizures. NCSE carries a poor prognosis with high mortality. <b>Disclosure:</b> Dr. Mohammed has nothing to disclose. Miss Stebbins has nothing to disclose. The institution of Dr. Shah has received research support from Eisai pharma .

Lower respiratory tract infections due to multi‑drug resistant pathogens in central nervous system injuries (Review).

Pneumonia is one of the most prevalent infections in the intensive care unit (ICU), where pneumonia may occur during hospitalization in the ICU as a complication. ICU patients with central nervous system (CNS) injuries are not an exception, and they may even be more susceptible to infections such as pneumonia due to issues such as swallowing difficulties, the requirement for mechanical ventilation, and extended hospital stay. Numerous common CNS injuries, such as ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage, can prolong hospital stay and increase the risk of pneumonia. Multidrug-resistant (MDR) microorganisms are a common and significant concern, with increased mortality in nosocomial pneumonia. However, research on pneumonia due to MDR pathogens in patients with CNS injuries is limited. The aim of the present review was to provide the current evidence regarding pneumonia due to MDR pathogens in patients with CNS injuries. The prevalence of pneumonia due to MDR pathogens in CNS injuries differs among different settings, types of CNS injuries, geographical areas, and time periods in which the studies were performed. Specific risk factors for the emergence of pneumonia due to MDR pathogens have been identified in ICUs and neurological rehabilitation units. Antimicrobial resistance is currently a global issue, although using preventive measures, early diagnosis, and close monitoring of MDR strains may lessen its impact. Since there is a lack of information on these topics, more multicenter prospective studies are required to offer insights into the clinical features and outcomes of these patients.