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Yuguero O, Bernal M, Farré J, Martinez-Alonso M, Vena A, Purroy F. Clinical complications after a traumatic brain injury and its relation with brain biomarkers. Sci Rep 2023; 13:20057. [PMID: 37973882 PMCID: PMC10654919 DOI: 10.1038/s41598-023-47267-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 11/11/2023] [Indexed: 11/19/2023] Open
Abstract
We aimed to find out which are the most frequent complications for patients who suffer a traumatic brain injury (TBI) and its relation with brain biomarker levels. We conducted a hospital cohort study with patients who attended the Hospital Emergency Department between 1 June 2018 and 31 December 2020. Different variables were collected such as biomarkers levels after 6 h and 12 h of TBI (S100, NSE, UCHL1 and GFAP), clinical and sociodemographic variables, complementary tests, and complications 48 h and 7 days after TBI. Qualitative variables were analysed with Pearson's chi-square test, and quantitative variables with the Mann-Whitney U test. A multivariate logistic regression model for the existence of complications one week after discharge was performed to assess the discriminatory capacity of the clinical variables. A total of 51 controls and 540 patients were included in this study. In the TBI group, the mean age was 83 years, and 53.9% of the patients were male. Complications at seven days were associated with the severity of TBI (p < 0.05) and the number of platelets (p = 0.016). All biomarkers except GFAP showed significant differences in their distribution of values according to gender, with significantly higher values of the three biomarkers for women with respect to men. Patients with complications presented significantly higher S100 values (p < 0.05). The patient's baseline status, the severity of the TBI and the S100 levels can be very important elements in determining whether a patient may develop complications in the few hours after TBI.
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Affiliation(s)
- Oriol Yuguero
- ERLab, Emergency Medicine Research Group, Institute for Biomedical Research Dr. Pifarré Foundation, IRBLLEIDA, Avda. Rovira Roure 80, 25198, Lleida, Spain.
- Faculty of Medicine, University of Lleida, Avda. Rovira Roure 80, 25198, Lleida, Spain.
| | - Maria Bernal
- Clinical Laboratory, University Hospital Arnau de Vilanova, Avda. Rovira Roure 80, 25198, Lleida, Spain
| | - Joan Farré
- Clinical Laboratory, University Hospital Arnau de Vilanova, Avda. Rovira Roure 80, 25198, Lleida, Spain
| | - Montserrat Martinez-Alonso
- Faculty of Medicine, University of Lleida, Avda. Rovira Roure 80, 25198, Lleida, Spain
- Systems Biology and Statistical Methods for Biomedical Research Group, Institute for Biomedical Research Dr. Pifarré Foundation, IRBLLEIDA, Avda. Rovira Roure 80, 25198, Lleida, Spain
| | - Ana Vena
- ERLab, Emergency Medicine Research Group, Institute for Biomedical Research Dr. Pifarré Foundation, IRBLLEIDA, Avda. Rovira Roure 80, 25198, Lleida, Spain
- Faculty of Medicine, University of Lleida, Avda. Rovira Roure 80, 25198, Lleida, Spain
| | - Francisco Purroy
- Faculty of Medicine, University of Lleida, Avda. Rovira Roure 80, 25198, Lleida, Spain
- Clinical neurosciences group, Institute for Biomedical Research Dr. Pifarré Foundation, IRBLLEIDA, Avda. Rovira Roure 80, 25198, Lleida, Spain
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Burzyńska M, Uryga A, Załuski R, Goździk A, Adamik B, Robba C, Goździk W. Cerebrospinal Fluid and Serum Biomarker Insights in Aneurysmal Subarachnoid Haemorrhage: Navigating the Brain-Heart Interrelationship for Improved Patient Outcomes. Biomedicines 2023; 11:2835. [PMID: 37893210 PMCID: PMC10604203 DOI: 10.3390/biomedicines11102835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/05/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
The pathophysiological mechanisms underlying severe cardiac dysfunction after aneurysmal subarachnoid haemorrhage (aSAH) remain poorly understood. In the present study, we focused on two categories of contributing factors describing the brain-heart relationship. The first group includes brain-specific cerebrospinal fluid (CSF) and serum biomarkers, as well as cardiac-specific biomarkers. The secondary category encompasses parameters associated with cerebral autoregulation and the autonomic nervous system. A group of 15 aSAH patients were included in the analysis. Severe cardiac complications were diagnosed in seven (47%) of patients. In the whole population, a significant correlation was observed between CSF S100 calcium-binding protein B (S100B) and brain natriuretic peptide (BNP) (rS = 0.62; p = 0.040). Additionally, we identified a significant correlation between CSF neuron-specific enolase (NSE) with cardiac troponin I (rS = 0.57; p = 0.025) and BNP (rS = 0.66; p = 0.029), as well as between CSF tau protein and BNP (rS = 0.78; p = 0.039). Patients experiencing severe cardiac complications exhibited notably higher levels of serum tau protein at day 1 (0.21 ± 0.23 [ng/mL]) compared to those without severe cardiac complications (0.03 ± 0.04 [ng/mL]); p = 0.009. Impaired cerebral autoregulation was noted in patients both with and without severe cardiac complications. Elevated serum NSE at day 1 was related to impaired cerebral autoregulation (rS = 0.90; p = 0.037). On the first day, a substantial, reciprocal correlation between heart rate variability low-to-high frequency ratio (HRV LF/HF) and both GFAP (rS = -0.83; p = 0.004) and S100B (rS = -0.83; p = 0.004) was observed. Cardiac and brain-specific biomarkers hold the potential to assist clinicians in providing timely insights into cardiac complications, and therefore they contribute to the prognosis of outcomes.
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Affiliation(s)
- Małgorzata Burzyńska
- Clinical Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, 50-370 Wroclaw, Poland
| | - Rafał Załuski
- Department of Neurosurgery, Wroclaw Medical University, 50-367 Wroclaw, Poland;
| | - Anna Goździk
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland;
| | - Barbara Adamik
- Clinical Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy;
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16145 Genoa, Italy
| | - Waldemar Goździk
- Clinical Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
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Giovannini G, Meletti S. Fluid Biomarkers of Neuro-Glial Injury in Human Status Epilepticus: A Systematic Review. Int J Mol Sci 2023; 24:12519. [PMID: 37569895 PMCID: PMC10420319 DOI: 10.3390/ijms241512519] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023] Open
Abstract
As per the latest ILAE definition, status epilepticus (SE) may lead to long-term irreversible consequences, such as neuronal death, neuronal injury, and alterations in neuronal networks. Consequently, there is growing interest in identifying biomarkers that can demonstrate and quantify the extent of neuronal and glial injury. Despite numerous studies conducted on animal models of status epilepticus, which clearly indicate seizure-induced neuronal and glial injury, as well as signs of atrophy and gliosis, evidence in humans remains limited to case reports and small case series. The implications of identifying such biomarkers in clinical practice are significant, including improved prognostic stratification of patients and the early identification of those at high risk of developing irreversible complications. Moreover, the clinical validation of these biomarkers could be crucial in promoting neuroprotective strategies in addition to antiseizure medications. In this study, we present a systematic review of research on biomarkers of neuro-glial injury in patients with status epilepticus.
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Affiliation(s)
- Giada Giovannini
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, 41126 Modena, Italy;
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio-Emilia, 41121 Modena, Italy
| | - Stefano Meletti
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, 41126 Modena, Italy;
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio-Emilia, 41121 Modena, Italy
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Wang CH, Chang WT, Su KI, Huang CH, Tsai MS, Chou E, Lu TC, Chen WJ, Lee CC, Chen SC. Neuroprognostic accuracy of blood biomarkers for post-cardiac arrest patients: A systematic review and meta-analysis. Resuscitation 2020; 148:108-117. [DOI: 10.1016/j.resuscitation.2020.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/26/2019] [Accepted: 01/09/2020] [Indexed: 01/12/2023]
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Neuron specific enolase as a marker of seizure related neuronal injury. Neurochem Int 2019; 131:104509. [PMID: 31404559 DOI: 10.1016/j.neuint.2019.104509] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/03/2019] [Accepted: 07/22/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND and purpose: Neuron specific enolase (NSE) is an established biomarker of neuronal damage. It is not clear how much seizures contribute to the neuronal damage, morbidity or mortality in critically ill neurology patients. The aim of this study is to determine the impact of seizures on neuronal injury in critically ill neurology patients by using neuron specific enolase as a biomarker. MATERIAL AND METHODS Forty patients with clinical evidence of acute central nervous system disease associated with seizures were included as critically ill neurology patients with seizures [CINPS] (age in years 38.8 ± 17.54, mean ± SD; 22 males) and 43 age and sex-matched acute central nervous system disease without seizures were recruited as critically ill neurology patients [CINP] (age in years 37.84 ± 17.38 years mean ± SD; 24 males) The serum NSE assays were performed in CINPS (within 24 h of last seizure) and in CINP using an enzyme immunoassay kit. RESULTS The level of serum neuron specific enolase was significantly higher in CINP with seizures compared to those without seizures. The length of ICU stay was more prolonged in those with seizures. There was a close correlation between the NSE levels and frequency of seizures. There was no significant difference in the mortality between both the groups. CONCLUSIONS NSE a marker of neuronal injury was elevated in patients with acute central nervous system diseases. It is significantly higher in patients with seizures in comparison to those without seizures. This warrants further studies to document aggressive treatment of seizures in acute neurologically ill patients can reduce neuronal damage.
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Luescher T, Mueller J, Isenschmid C, Kalt J, Rasiah R, Tondorf T, Gamp M, Becker C, Sutter R, Tisljar K, Schuetz P, Marsch S, Hunziker S. Neuron-specific enolase (NSE) improves clinical risk scores for prediction of neurological outcome and death in cardiac arrest patients: Results from a prospective trial. Resuscitation 2019; 142:50-60. [PMID: 31306716 DOI: 10.1016/j.resuscitation.2019.07.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/26/2019] [Accepted: 07/04/2019] [Indexed: 10/26/2022]
Abstract
AIM Neuron-specific enolase (NSE) increases in response to brain injury and is recommended for outcome prediction in cardiac arrest patients. Our aim was to investigate whether NSE measured at different days after a cardiac arrest and its kinetics would improve the prognostic ability of two cardiac arrest specific risk scores. METHODS Within this prospective observational study, we included consecutive adult patients after cardiac arrest. We calculated the Out-of-hospital cardiac arrest (OHCA) score and the Cardiac Arrest Hospital Prognosis (CAHP) score upon ICU admission and measured serum NSE upon admission and days 1, 2, 3, 5 and 7. We calculated logistic regression models to study associations of scores and NSE levels with neurological outcome defined by Cerebral Performance Category (CPC) scale and in-hospital death. RESULTS From 336 included patients, 180 (54%) survived until hospital discharge, of which 150 (45%) had a good neurological outcome. NSE at day 3 showed the highest prognostic accuracy (discrimination) for neurological outcome (area under the curve (AUC) 0.89) and in-hospital mortality (AUC 0.88). These results were robust in reclassification statistics and across different subgroups. NSE kinetics with admission levels serving as a baseline did not further improve prognostication. NSE on day 3 significantly improved discrimination of both clinical risk scores (CAHP from AUC 0.81 to 0.91; OHCA from AUC 0.79 to 0.89). CONCLUSION NSE measured at day 3 significantly improves clinical risk scores for outcome prediction in cardiac arrest patients and may thus add to clinical decision making about escalation or withdrawal of therapy in this vulnerable patient population.
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Affiliation(s)
- Tanja Luescher
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Switzerland; Medical Communication and Psychosomatic Medicine, University Hospital Basel, Switzerland
| | - Jonas Mueller
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Switzerland; Medical Communication and Psychosomatic Medicine, University Hospital Basel, Switzerland
| | - Cyril Isenschmid
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Switzerland; Medical Communication and Psychosomatic Medicine, University Hospital Basel, Switzerland
| | - Jeanice Kalt
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Switzerland; Medical Communication and Psychosomatic Medicine, University Hospital Basel, Switzerland
| | - Roshaani Rasiah
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Switzerland; Medical Communication and Psychosomatic Medicine, University Hospital Basel, Switzerland
| | - Theresa Tondorf
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Switzerland
| | - Martina Gamp
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Switzerland
| | - Christoph Becker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Switzerland
| | - Raoul Sutter
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Switzerland
| | - Kai Tisljar
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Switzerland
| | - Philipp Schuetz
- Medical faculty of the University of Basel, Switzerland; Department of Internal Medicine, Kantonsspital Aarau, Switzerland
| | - Stephan Marsch
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Switzerland; Medical faculty of the University of Basel, Switzerland
| | - Sabina Hunziker
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Switzerland; Medical Communication and Psychosomatic Medicine, University Hospital Basel, Switzerland; Medical faculty of the University of Basel, Switzerland.
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Miao W, Sun Q, Wang H, Li H. The maximum value of bispectral index predicts outcome in hypoxic-ischemic encephalopathy after resuscitation, better than minimum or mean value. Brain Inj 2018; 32:1135-1141. [PMID: 29851509 DOI: 10.1080/02699052.2018.1476732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Although bispectral index (BIS) has been widely used for predicting neurological outcomes in clinical practice, its optimal value concerning maximum (BISmax), minimum (BISmin) and mean (BISmean) on accurately predicting the prognosis of patients with hypoxic-ischemic encephalopathy (HIE) after resuscitation has not been clearly determined. METHODS For a total number of 45 cases, the duration of each BIS measurement was 12 h, with the data collected at a 30 min interval. Outcome was recorded as survival and non-survival count 60 days after the resuscitation. Receiver operator characteristic curve was used to assess the BISmax, BISmin and BISmean for predicting clinical outcome. RESULTS By the end of observation, 20 cases (44.4%) survived with a significantly higher BISmax. The area under the curve for BISmax of predicting survival was the highest compared to BISmin and BISmean. The optimal cut-off value of BISmax was 71.5 with 100% sensitivity and 60% specificity. Ten patients presented BIS value down to zero at any time point did not survive the observation. CONCLUSION The BISmax is a better outcome predictor than BISmin or BISmean for patients with HIE after resuscitation. Lower BISmax represents higher risk of mortality. Additionally, BIS value decreases to zero represents a poor outcome.
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Affiliation(s)
- Wenli Miao
- a Department of Critical Care Medicine , No. 401 Hospital of the Chinese Peoples' Liberation Army , Qingdao , China.,b Department of Critical Care Medicine , Huikang Hospital of Qingdao University Medical Group , Qingdao , China
| | - Qing Sun
- c Department of Hyperbaric Medicine , No. 401 Hospital of the Chinese Peoples' Liberation Army , Qingdao , China
| | - Hongdao Wang
- a Department of Critical Care Medicine , No. 401 Hospital of the Chinese Peoples' Liberation Army , Qingdao , China
| | - Hailing Li
- a Department of Critical Care Medicine , No. 401 Hospital of the Chinese Peoples' Liberation Army , Qingdao , China
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8
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IMPACT Score for Traumatic Brain Injury: Validation of the Prognostic Tool in a Spanish Cohort. J Head Trauma Rehabil 2018; 33:46-52. [DOI: 10.1097/htr.0000000000000292] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Moon JM, Chun BJ, Lee SD, Jung EJ. Serum neuron-specific enolase levels at presentation and long-term neurological sequelae after acute charcoal burning-induced carbon monoxide poisoning. Clin Toxicol (Phila) 2017; 56:751-758. [PMID: 29239210 DOI: 10.1080/15563650.2017.1415347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study aimed to investigate whether clinical parameters and serum neuron-specific enolase (NSE) levels measured at emergency department (ED) presentation help stratify the risk of acute or delayed persistent severe neurological sequelae after acute carbon monoxide (CO) poisoning induced by charcoal burning. METHODS This retrospective study included 236 patients who suffered from CO poisoning. Demographic information, serum NSE levels measured in the ED, treatment, clinical course, and long-term neurological outcomes were recorded. RESULTS The median serum NSE level at presentation was 15.5 (10.9-22.7) ng/mL. No differences were observed in the duration of CO exposure; the initial Glasgow Coma Scale (GCS) score; the levels of arterial HCO3-, white blood cells (WBCs), C-reactive protein (CRP) or troponin I; or the frequency of abnormal diffusion-weighted imaging finding at presentation among the groups with different serum NSE levels at presentation. The incidences of acute and delayed persistent neurologic sequelae assessed at 22.3 months after acute charcoal CO poisoning were 5.1% and 8.5%, respectively. No difference in the NSE level was observed between patients stratified according to long-term neurological status. According to the multinomial logistic regression analysis, age, serum CRP levels and the initial GCS score were risk factors for the two types of persistent severe neurological sequelae, whereas troponin I levels were associated only with the acute persistent severe neurological sequelae. However, the adjusted NSE level was not a risk factor for any persistent neurological sequelae. CONCLUSIONS Serum NSE levels at presentation were not correlated with the risk of acute or delayed persistent neurological sequelae. Further studies with blood sampling at optimal time points and serial measurements should be conducted. Age, initial GCS score, and CRP levels may be risk factors for persistent severe neurological sequelae.
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Affiliation(s)
- J M Moon
- a Department of Emergency Medicine , Chonnam National University Medical School , Gwangju , South Korea
| | - B J Chun
- a Department of Emergency Medicine , Chonnam National University Medical School , Gwangju , South Korea
| | - S D Lee
- a Department of Emergency Medicine , Chonnam National University Medical School , Gwangju , South Korea
| | - E J Jung
- a Department of Emergency Medicine , Chonnam National University Medical School , Gwangju , South Korea
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De Santis P, Lamanna I, Mavroudakis N, Legros B, Vincent JL, Creteur J, Taccone FS. The potential role of auditory evoked potentials to assess prognosis in comatose survivors from cardiac arrest. Resuscitation 2017; 120:119-124. [PMID: 28942010 DOI: 10.1016/j.resuscitation.2017.09.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/10/2017] [Accepted: 09/19/2017] [Indexed: 11/26/2022]
Abstract
AIM 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). METHODS Retrospective analysis of data from all adult patients (>18years 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). RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Paolo De Santis
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Irene Lamanna
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Nicolas Mavroudakis
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Benjamin Legros
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium.
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Taccone FS, Baar I, De Deyne C, Druwe P, Legros B, Meyfroidt G, Ossemann M, Gaspard N. Neuroprognostication after adult cardiac arrest treated with targeted temperature management: task force for Belgian recommendations. Acta Neurol Belg 2017; 117:3-15. [PMID: 28168412 DOI: 10.1007/s13760-017-0755-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/25/2017] [Indexed: 12/27/2022]
Abstract
The prognosis of patients who are admitted to the hospital after cardiac arrest often relies on neurological examination, which could be significantly influenced by the use of sedative drugs or the implementation of targeted temperature management. The need for early and accurate prognostication is crucial as up to 15-20% of patients could be considered as having a poor outcome and may undergo withdrawal of life-sustaining therapies while a complete neurological recovery is still possible. As current practice in Belgium is still based on a very early assessment of neurological function in these patients, the Belgian Society of Intensive Care Medicine created a multidisciplinary Task Force to provide an optimal approach for monitoring and refine prognosis of CA survivors. This Task Force underlined the importance to use a multimodal approach using several additional tools (e.g., electrophysiological tests, neuroimaging, biomarkers) and to refer cases with uncertain prognosis to specialized centers to better evaluate the extent of brain injury in these patients.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Ingrid Baar
- Department of Neurology, Antwerp University Hospital, 2650, Edegem, Belgium
| | - Cathy De Deyne
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg ZOL, Schiepse Bos 6, 3600, Genk, Belgium
| | - Patrick Druwe
- Department of Intensive Care, Ghent University Hospital, De Pintelaan, 185, 9000, Ghent, Belgium
| | - Benjamin Legros
- Department of Neurology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Geert Meyfroidt
- Department of Intensive Care, UZ Leuven, Herestraat 49, box 7003 63, 3000, Leuven, Belgium
| | - Michel Ossemann
- Department of Neurology, CHU UCL Namur, Université Catholique de Louvain, Avenue Gaston Thérasse, 1, 5530, Yvoir, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
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Sanganalmath SK, Gopal P, Parker JR, Downs RK, Parker JC, Dawn B. Global cerebral ischemia due to circulatory arrest: insights into cellular pathophysiology and diagnostic modalities. Mol Cell Biochem 2016; 426:111-127. [PMID: 27896594 DOI: 10.1007/s11010-016-2885-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/08/2016] [Indexed: 02/07/2023]
Abstract
Circulatory arrest (CA) remains a major unresolved public health problem in the United States; the annual incidence of which is ~0.50 to 0.55 per 1000 population. Despite seminal advances in therapeutic approaches over the past several decades, brain injury continues to be the leading cause of morbidity and mortality after CA. In brief, CA typically results in global cerebral ischemia leading to delayed neuronal death in the hippocampal pyramidal cells as well as in the cortical layers. The dynamic changes occurring in neurons after CA are still unclear, and predicting these neurological changes in the brain still remains a difficult issue. It is hypothesized that the "no-flow" period produces a cytotoxic cascade of membrane depolarization, Ca2+ ion influx, glutamate release, acidosis, and resultant activation of lipases, nucleases, and proteases. Furthermore, during reperfusion injury, neuronal death occurs due to the generation of free radicals by interfering with the mitochondrial respiratory chain. The efficacy of many pharmacological agents for CA patients has often been disappointing, reflecting our incomplete understanding of this enigmatic disease. The primary obstacles to the development of a neuroprotective therapy in CA include uncertainties with regard to the precise cause(s) of neuronal dysfunction and what to target. In this review, we summarize our knowledge of the pathophysiology as well as specific cellular changes in brain after CA and revisit the most important neurofunctional, neuroimaging techniques, and serum biomarkers as potent predictors of neurologic outcome in CA patients.
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Affiliation(s)
- Santosh K Sanganalmath
- Division of Cardiovascular Diseases, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA.
| | - Purva Gopal
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - John R Parker
- Division of Neuropathology, Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY, USA
| | - Richard K Downs
- Division of Neuroradiology, Department of Radiology, University of Louisville, Louisville, KY, USA
| | - Joseph C Parker
- Division of Neuropathology, Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY, USA
| | - Buddhadeb Dawn
- Division of Cardiovascular Diseases, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
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Anderson BJ, Reilly JP, Shashaty MGS, Palakshappa JA, Wysoczanski A, Dunn TG, Kazi A, Tommasini A, Mikkelsen ME, Schweickert WD, Kolson DL, Christie JD, Meyer NJ. Admission plasma levels of the neuronal injury marker neuron-specific enolase are associated with mortality and delirium in sepsis. J Crit Care 2016; 36:18-23. [PMID: 27546742 DOI: 10.1016/j.jcrc.2016.06.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/13/2016] [Accepted: 06/13/2016] [Indexed: 12/30/2022]
Abstract
PURPOSE Neuron-specific enolase (NSE) concentrations are prognostic following traumatic and anoxic brain injury and may provide a method to quantify neuronal injury in other populations. We determined the association of admission plasma NSE concentrations with mortality and delirium in critically ill septic patients. METHODS We performed a retrospective analysis of 124 patients from a larger sepsis cohort. Plasma NSE was measured in the earliest blood draw at intensive care unit admission. Primary outcomes were 30-day mortality and intensive care unit delirium determined by chart review. RESULTS Sixty-one patients (49.2%) died within 30 days, and delirium developed in 34 (31.5%) of the 108 patients who survived at least 24 hours and were not persistently comatose. Each doubling of the NSE concentration was associated with a 7.3% (95% confidence interval [CI] 2.5-12.0, P= .003) increased risk of 30-day mortality and a 5.2% (95% CI 3.2-7.2, P< .001) increased risk of delirium. An NSE concentration >12.5 μg/L was independently associated with a 23.3% (95% CI 6.7-39.9, P= .006) increased risk of 30-day mortality and a 29.3% (95% CI 8.8-49.8, P= .005) increased risk of delirium. CONCLUSIONS Higher plasma NSE concentrations were associated with mortality and delirium in critically ill septic patients, suggesting that NSE may have utility as a marker of neuronal injury in sepsis.
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Affiliation(s)
- Brian J Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Jessica A Palakshappa
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Alex Wysoczanski
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Thomas G Dunn
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Altaf Kazi
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Anna Tommasini
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - William D Schweickert
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Dennis L Kolson
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
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Cirillo F, DeRobertis E, Hinkelbein J. Extracorporeal life support for refractory out-of-hospital cardiac arrest in adults. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2016. [DOI: 10.1016/j.tacc.2016.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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15
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Utilidad de los biomarcadores en el pronóstico del traumatismo craneoencefálico grave. Med Intensiva 2016; 40:105-12. [DOI: 10.1016/j.medin.2015.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/03/2015] [Accepted: 11/18/2015] [Indexed: 11/21/2022]
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Abstract
To determine the optimal use and indications of electroencephalography (EEG) in critical care management of acute brain injury (ABI). An electronic literature search was conducted for articles in English describing electrophysiological monitoring in ABI from January 1990 to August 2013. A total of 165 studies were included. EEG is a useful monitor for seizure and ischemia detection. There is a well-described role for EEG in convulsive status epilepticus and cardiac arrest (CA). Data suggest EEG should be considered in all patients with ABI and unexplained and persistent altered consciousness and in comatose intensive care unit (ICU) patients without an acute primary brain condition who have an unexplained impairment of mental status. There remain uncertainties about certain technical details, e.g., the minimum duration of EEG studies, the montage, and electrodes. Data obtained from both EEG and EP studies may help estimate prognosis in ABI patients, particularly following CA and traumatic brain injury. Data supporting these recommendations is sparse, and high quality studies are needed. EEG is used to monitor and detect seizures and ischemia in ICU patients and indications for EEG are clear for certain disease states, however, uncertainty remains on other applications.
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Chou SHY, Robertson CS. Monitoring biomarkers of cellular injury and death in acute brain injury. Neurocrit Care 2015; 21 Suppl 2:S187-214. [PMID: 25208676 DOI: 10.1007/s12028-014-0039-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Molecular biomarkers have revolutionalized diagnosis and treatment of many diseases, such as troponin use in myocardial infarction. Urgent need for high-fidelity biomarkers in neurocritical care has resulted in numerous studies reporting potential candidate biomarkers. METHODS We performed an electronic literature search and systematic review of English language articles on cellular/molecular biomarkers associated with outcome and with disease-specific secondary complications in adult patients with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), and post-cardiac arrest hypoxic ischemic encephalopathic injuries (HIE). RESULTS A total of 135 articles were included. Though a wide variety of potential biomarkers have been identified, only neuron-specific enolase has been validated in large cohorts and shows 100% specificity for poor outcome prediction in HIE patients not treated with therapeutic hypothermia. There are many promising candidate blood and CSF biomarkers in SAH, AIS, ICH, and TBI, but none yet meets criteria for routine clinical use. CONCLUSION Current studies vary significantly in patient selection, biosample collection/processing, and biomarker measurement protocols, thereby limiting the generalizability of overall results. Future large prospective studies with standardized treatment, biosample collection, and biomarker measurement and validation protocols are necessary to identify high-fidelity biomarkers in neurocritical care.
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Affiliation(s)
- Sherry H-Y Chou
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA,
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18
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Taccone FS, Crippa IA, Dell'Anna AM, Scolletta S. Neuroprotective strategies and neuroprognostication after cardiac arrest. Best Pract Res Clin Anaesthesiol 2015; 29:451-64. [PMID: 26670816 DOI: 10.1016/j.bpa.2015.08.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/20/2015] [Indexed: 12/23/2022]
Abstract
Neurocognitive disturbances are common among survivors of cardiac arrest (CA). Although initial management of CA, including bystander cardiopulmonary resuscitation, optimal chest compression, and early defibrillation, has been implemented continuously over the last years, few therapeutic interventions are available to minimize or attenuate the extent of brain injury occurring after the return of spontaneous circulation. In this review, we discuss several promising drugs that could provide some potential benefits for neurological recovery after CA. Most of these drugs have been investigated exclusively in experimental CA models and only limited clinical data are available. Further research, which also considers combined neuroprotective strategies that target multiple pathways involved in the pathophysiology of postanoxic brain injury, is certainly needed to demonstrate the effectiveness of these interventions in this setting. Moreover, the evaluation of neurological prognosis of comatose patients after CA remains an important challenge that requires the accurate use of several tools. As most patients with CA are currently treated with targeted temperature management (TTM), combined with sedative drug therapy, especially during the hypothermic phase, the reliability of neurological examination in evaluating these patients is delayed to 72-96 h after admission. Thus, additional tests, including electrophysiological examinations, brain imaging and biomarkers, have been largely implemented to evaluate earlier the extent of brain damage in these patients.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium.
| | - Ilaria Alice Crippa
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - Antonio Maria Dell'Anna
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - Sabino Scolletta
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
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Zenaide PV, Gusmao-Flores D. Biomarkers in septic encephalopathy: a systematic review of clinical studies. Rev Bras Ter Intensiva 2015; 25:56-62. [PMID: 23887761 PMCID: PMC4031860 DOI: 10.1590/s0103-507x2013000100011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/20/2013] [Indexed: 01/06/2023] Open
Abstract
Objective The aim of this study was to systematically review the importance of
neuron-specific enolase and S100 beta for diagnosing and monitoring septic
encephalopathy. Methods A PubMed database search was performed to identify studies that evaluated S100
beta and neuron-specific enolase serum levels in patients with sepsis and that
were published between January 2000 and April 2012. Only human studies that
employed an additional method of neurological assessment were selected. Results Nine studies were identified, seven of which associated high concentrations of
S100 beta and neuron-specific enolase with the development of septic
encephalopathy. Four studies also associated these concentrations with increased
mortality. However, two studies did not find such an association when they
evaluated S100 beta levels, and one of these studies did not observe a correlation
between neuron-specific enolase and septic encephalopathy. Conclusion S100 beta and neuron-specific enolase are promising biomarkers for diagnosing and
monitoring patients with septic encephalopathy, but more research is
necessary.
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Affiliation(s)
- Paula Veriato Zenaide
- Academic Medical Course, Escola Bahiana de Medicina e Saúde Pública - Salvador, Brazil.
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20
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Isgrò MA, Bottoni P, Scatena R. Neuron-Specific Enolase as a Biomarker: Biochemical and Clinical Aspects. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 867:125-43. [PMID: 26530364 DOI: 10.1007/978-94-017-7215-0_9] [Citation(s) in RCA: 300] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neuron-specific enolase (NSE) is known to be a cell specific isoenzyme of the glycolytic enzyme enolase. In vertebrate organisms three isozymes of enolase, expressed by different genes, are present: enolase α is ubiquitous; enolase β is muscle-specific and enolase γ is neuron-specific. The expression of NSE, which occurs as γγ- and αγ-dimer, is a late event in neural differentiation, thus making it a useful index of neural maturation.NSE is a highly specific marker for neurons and peripheral neuroendocrine cells. As a result of the findings of NSE in specific tissues under normal conditions, increased body fluids levels of NSE may occur with malignant proliferation and thus can be of value in diagnosis, staging and treatment of related neuroendocrine tumours (NETs).NSE is currently the most reliable tumour marker in diagnosis, prognosis and follow-up of small cell lung cancer (SCLC), even though increased levels of NSE have been reported also in non-small cell lung cancer (NSCLC). The level of NSE correlates with tumour burden, number of metastatic sites and response to treatment.NSE can be also useful at diagnosis of NETs and gastroenteropancreatic (GEP)-NETs.Raised serum levels of NSE have been found in all stages of neuroblastoma, although the incidence of increased concentration is greater in widespread and metastatic disease. Moreover, NSE determination in cord blood offers an early postnatal possibility of confirming the diagnosis of neuroblastoma in newborns.NSE has been demonstrated to provide quantitative measures of brain damage and/or to improve the diagnosis and the outcome evaluation in ischaemic stroke, intracerebral hemorrhage, seizures, comatose patients after cardiopulmonary resuscitation for cardiac arrest and traumatic brain injury.Increased NSE serum levels have also been found associated with melanoma, seminoma, renal cell carcinoma, Merkel cell tumour, carcinoid tumours, dysgerminomas and immature teratomas, malignant phaechromocytoma, Guillain-Barré syndrome and Creutzfeldt-Jakob disease.
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Affiliation(s)
- Maria Antonietta Isgrò
- Institute of Biochemistry and Clinical Biochemistry, Catholic University of the Sacred Heart, Largo Agostino Gemelli 8, 00168, Rome, Italy. .,Department of Diagnostic and Molecular Medicine, Catholic University of the Sacred Heart, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Patrizia Bottoni
- Institute of Biochemistry and Clinical Biochemistry, School of Medicine, Catholic University, Largo Gemelli 8, 00168, Rome, Italy
| | - Roberto Scatena
- Institute of Biochemistry and Clinical Biochemistry, School of Medicine, Catholic University, Largo Gemelli 8, 00168, Rome, Italy
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21
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Impact of intra-arrest therapeutic hypothermia in outcomes of prehospital cardiac arrest: a randomized controlled trial. Intensive Care Med 2014; 40:1832-42. [DOI: 10.1007/s00134-014-3519-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 10/09/2014] [Indexed: 10/24/2022]
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Fink EL, Berger RP, Clark RSB, Watson RS, Angus DC, Richichi R, Panigrahy A, Callaway CW, Bell MJ, Kochanek PM. Serum biomarkers of brain injury to classify outcome after pediatric cardiac arrest*. Crit Care Med 2014; 42:664-74. [PMID: 24164954 PMCID: PMC4478619 DOI: 10.1097/01.ccm.0000435668.53188.80] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Morbidity and mortality in children with cardiac arrest largely result from neurologic injury. Serum biomarkers of brain injury can potentially measure injury to neurons (neuron-specific enolase), astrocytes (S100b), and axons (myelin basic protein). We hypothesized that serum biomarkers can be used to classify outcome from pediatric cardiac arrest. DESIGN Prospective observational study. SETTING Single tertiary pediatric hospital. PATIENTS Forty-three children with cardiac arrest. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We measured serum neuron-specific enolase, S100b, and myelin basic protein on days 1-4 and 7 after cardiac arrest. We recorded demographics, details of the cardiac arrest and resuscitation, and Pediatric Cerebral Performance Category at hospital discharge and 6 months. We analyzed the association of biomarker levels at 24, 48, and 72 hours with favorable (Pediatric Cerebral Performance Category 1-3) or unfavorable (Pediatric Cerebral Performance Category 4-6) outcome and mortality. Forty-three children (49% female; mean age of 5.9 ± 6.3) were enrolled and 17 (40%) died. Serum S100b concentrations peaked earliest, followed by neuron-specific enolase and finally myelin basic protein. Serum neuron-specific enolase and S100b concentrations were increased in the unfavorable versus favorable outcome group and in subjects who died at all time points (all p < 0.05). Serum myelin basic protein at 24 and 72 hours correctly classified survival but not good versus poor outcome. Using best specificity, serum S100b and neuron-specific enolase had optimal positive and negative predictive values at 24 hours to classify both favorable versus unfavorable outcome and survival, whereas serum myelin basic protein's best accuracy occurred at 48 hours. Receiver operator curves for serum S100b and neuron-specific enolase to classify favorable versus unfavorable outcome at 6 months were superior to clinical variables. CONCLUSIONS Preliminary data show that serum S100b, neuron-specific enolase, and myelin basic protein may aid in outcome classification of children surviving cardiac arrest.
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Affiliation(s)
- Ericka L Fink
- 1Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA. 2Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA. 3Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. 4Statistical Analysis and Measurement Consultants, Inc., Lanexa, VA. 5Department of Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA. 6Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
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Taccone F, Cronberg T, Friberg H, Greer D, Horn J, Oddo M, Scolletta S, Vincent JL. How to assess prognosis after cardiac arrest and therapeutic hypothermia. Crit Care 2014; 18:202. [PMID: 24417885 PMCID: PMC4056000 DOI: 10.1186/cc13696] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The prognosis of patients who are admitted in a comatose state following successful resuscitation after cardiac arrest remains uncertain. Although the introduction of therapeutic hypothermia (TH) and improvements in post-resuscitation care have significantly increased the number of patients who are discharged home with minimal brain damage, short-term assessment of neurological outcome remains a challenge. The need for early and accurate prognostic predictors is crucial, especially since sedation and TH may alter the neurological examination and delay the recovery of motor response for several days. The development of additional tools, including electrophysiological examinations (electroencephalography and somatosensory evoked potentials), neuroimaging and chemical biomarkers, may help to evaluate the extent of brain injury in these patients. Given the extensive literature existing on this topic and the confounding effects of TH on the strength of these tools in outcome prognostication after cardiac arrest, the aim of this narrative review is to provide a practical approach to post-anoxic brain injury when TH is used. We also discuss when and how these tools could be combined with the neurological examination in a multimodal approach to improve outcome prediction in this population.
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Improved early postresuscitation EEG activity for animals treated with hypothermia predicted 96 hr neurological outcome and survival in a rat model of cardiac arrest. BIOMED RESEARCH INTERNATIONAL 2013; 2013:312137. [PMID: 24369012 PMCID: PMC3867829 DOI: 10.1155/2013/312137] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 10/22/2013] [Accepted: 10/23/2013] [Indexed: 11/25/2022]
Abstract
Purpose. To investigate the effect of hypothermia on 96 hr neurological outcome and survival by quantitatively characterizing early postresuscitation EEG in a rat model of cardiac arrest. Materials and Methods. In twenty male Sprague-Dawley rats, cardiac arrest was induced through high frequency transesophageal cardiac pacing. Cardiopulmonary resuscitation was initiated after 5 mins untreated arrest. Immediately after resuscitation, animals were randomized to either 2 hrs of hypothermia (N = 10) or normothermia (N = 10). EEG, ECG, aortic pressure, and core temperature were continuously recorded for 6 hrs. Neurological outcome was evaluated daily during the 96 hrs postresuscitation period. Results. No differences in the baseline measurements and resuscitation outcome were observed between groups. However, 96 hr neurological deficit score (204 ± 255 versus 500 ± 0, P = 0.005) and survival (6/10 versus 0/10, P = 0.011) were significantly better in the hypothermic group. Quantitative analysis of early postresuscitation EEG revealed that burst frequency and spectrum entropy were greatly improved in the hypothermic group and correlated with 96 hr neurological outcome and survival. Conclusion. The improved burst frequency during burst suppression period and preserved spectrum entropy after restoration of continuous background EEG activity for animals treated with hypothermia predicted favorable neurological outcome and survival in this rat model of cardiac arrest.
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Miao W, Zhang Y, Li H. Bispectral index predicts deaths within 2 weeks in coma patients, a better predictor than serum neuron-specific enolase or S100 protein. J Anesth 2013; 27:855-61. [DOI: 10.1007/s00540-013-1654-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 06/04/2013] [Indexed: 10/26/2022]
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Floerchinger B, Philipp A, Foltan M, Keyser A, Camboni D, Lubnow M, Lunz D, Hilker M, Schmid C. Neuron-specific enolase serum levels predict severe neuronal injury after extracorporeal life support in resuscitation. Eur J Cardiothorac Surg 2013; 45:496-501. [PMID: 23878016 DOI: 10.1093/ejcts/ezt370] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Extracorporeal life support (ECLS) is a rescue option in critically ill patients. Since fast available and appropriate for respiratory and circulatory failure, it is frequently applied in resuscitation scenarios. Neurological injury is a complication common in ECLS patients limiting outcome, particularly after resuscitation. In this study, the institutional ECLS database was used to correlate neuron-specific enolase (NSE) serum peak values with outcome of patients supported with venoarterial (VA) ECLS during cardiopulmonary resuscitation (CPR). METHODS From January 2011 to August 2012, 31 patients were provided with a VA ECLS during CPR (external cardiac massage). Serum NSE peaks were monitored and correlated with neurological outcome and hospital mortality. Patients were divided into two groups with mild-to-moderate and high NSE levels (cut-off value 100 μg/l). RESULTS High NSE levels were seen in 7 patients (mean 218 ± 155 μg/l) and mild-to-moderate levels in 24 patients (50 ± 23 μg/l, P = 0.0001). Duration of extracoporeal support was comparable in both groups (6.3 ± 7.5 vs 5.0 ± 4.5 days, P = n.s.). Patients with mild-to-moderate NSE levels were significantly older than those with high NSE levels (58 ± 16 vs 44 ± 15 years, P = 0.02). Six patients with high NSE levels (86%) developed severe neurological complications. Though 4 patients could be weaned from extracorporeal support, hospital mortality was 86% (6 patients). In contrast, patients with mild-to-moderate NSE levels had a hospital mortality of 46% (11 patients). Eighteen patients (75%) could be weaned from the device, and incidence of major neurological events was 29% (6 patients) only. Serum pH and lactate levels before ECLS implantation were significantly lower in patients with mild-to-moderate NSE values (pH: 7.23 ± 0.04 vs 6.93 ± 0.12, P = 0.039; lactate: 106 ± 11 vs 161 ± 16 mg/l, P = 0.023). CONCLUSIONS High NSE serum levels after ECLS correspond to poor neurological outcome and considerable mortality. Therefore, early neuroimaging is reasonable for determining therapeutic strategies in patients with high NSE peaks after resuscitation and extracorporeal support.
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Affiliation(s)
- Bernhard Floerchinger
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Mlynash M, Buckwalter MS, Okada A, Caulfield AF, Venkatasubramanian C, Eyngorn I, Verbeek MM, Wijman CAC. Serum Neuron-Specific Enolase Levels from the Same Patients Differ Between Laboratories: Assessment of a Prospective Post-cardiac Arrest Cohort. Neurocrit Care 2013; 19:161-6. [DOI: 10.1007/s12028-013-9867-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
BACKGROUND The prediction of neurologic outcome is a fundamental concern in the resuscitation of patients with severe brain injury. OBJECTIVE To provide an evidence-based update on neurologic prognosis following traumatic brain injury and hypoxic-ischemic encephalopathy after cardiac arrest. DATA SOURCE Search of the PubMed database and manual review of bibliographies from selected articles to identify original data relating to prognostic methods and outcome prediction models in patients with neurologic trauma or hypoxic-ischemic encephalopathy. DATA SYNTHESIS AND CONCLUSION Articles were scrutinized regarding study design, population evaluated, interventions, outcomes, and limitations. Outcome prediction in severe brain injury is reliant on features of the neurologic examination, anatomical and physiological changes identified with CT and MRI, abnormalities detected with electroencephalography and evoked potentials, and physiological and biochemical derangements at both the brain and systemic levels. Use of such information in univariable association studies generally lacks specificity in classifying neurologic outcome. Furthermore, the accuracy of established prognostic classifiers may be affected by the introduction of outcome-modifying interventions, such as therapeutic hypothermia following cardiac arrest. Although greater specificity may be achieved with scoring systems derived from multivariable models, they generally fail to predict outcome with sufficient accuracy to be meaningful at the single patient level. Discriminative models which integrate knowledge of genetic determinants and biologic processes governing both injury and repair and account for the effects of resuscitative and rehabilitative care are needed.
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Scolletta S, Donadello K, Santonocito C, Franchi F, Taccone FS. Biomarkers as predictors of outcome after cardiac arrest. Expert Rev Clin Pharmacol 2013; 5:687-99. [PMID: 23234326 DOI: 10.1586/ecp.12.64] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Cardiac arrest (CA) is a major health and economic problem. Management of patients resuscitated from CA is challenging for clinicians, and the mortality rate of those who achieve return of spontaneous circulation remains high. Hypoxic brain injury, cardiovascular abnormalities and systemic ischemia/reperfusion response characterize the so-called 'postcardiac arrest syndrome', which could lead to multiple organ failure and poor outcome after CA. The magnitude of these disorders differs in individual patients, mainly based on the cause and duration of CA and on the severity of the ischemic episode. Prognostication of outcome after CA is of importance because it could help physicians on triage decisions and readdress the overall management. A number of factors are thought to influence the prognosis of patients after CA, but due to the heterogeneity of CA population and scenarios no single factor has been identified as a reliable predictor of outcome and the timing and optimal approach to prognostication is still controversial. Biomarkers represent a growing area of interest in this field, as they may provide clinicians with early information on the severity of organ dysfunction to make a decision on clinical strategies and prognosticate outcome. In this article, the authors will focus on cardiac, neurological and inflammatory biomarkers as potential predictors of outcome after CA.
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Affiliation(s)
- Sabino Scolletta
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, Belgium.
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Invasive versus non-invasive cooling after in- and out-of-hospital cardiac arrest: a randomized trial. Clin Res Cardiol 2013; 102:607-14. [PMID: 23644718 DOI: 10.1007/s00392-013-0572-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 04/17/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Mild induced hypothermia (MIH) is indicated for comatose survivors of sudden cardiac arrest (SCA) to improve clinical outcome. In this study, we compared the efficacy of two different cooling devices for temperature management in SCA survivors. METHODS Between April 2008 and August 2009, 80 patients after survived in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) were included in this prospective, randomized, single center study. Hypothermia was induced after randomization by either invasive Coolgard(®) cooling or non-invasive ArcticSun(®) surface cooling at 33.0 °C core body temperature for 24 h followed by active rewarming. The primary endpoint was defined as the efficacy of both cooling systems, measured by neuron-specific enolase (NSE) levels as a surrogate parameter for brain damage. Secondary efficacy endpoints were the clinical and neurological outcome, time to start of cooling and reaching the target temperature, target temperature-maintenance and hypothermia-associated complications. RESULTS NSE at 72 h did not differ significantly between the 2 groups with 16.5 ng/ml, interquartile range 11.8-46.5 in surface-cooled patients versus 19.0 ng/ml, interquartile range 11.0-42.0 in invasive-cooled patients, p = 0.99. Neurological and clinical outcome was similar in both groups. Target temperature of 33.0 °C was maintained more stable in the invasive group (33.0 versus 32.7 °C, p < 0.001). Bleeding complications were more frequent with invasive cooling (n = 17 [43.6 %] versus n = 7 [17.9 %]; p = 0.03). CONCLUSION Invasive cooling has advantages with respect to temperature management over surface cooling; however, did not result in different outcome as measured by NSE release in SCA survivors. Bleeding complications were more frequently encountered by invasive cooling.
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Zellner T, Gärtner R, Schopohl J, Angstwurm M. NSE and S-100B are not sufficiently predictive of neurologic outcome after therapeutic hypothermia for cardiac arrest. Resuscitation 2013; 84:1382-6. [PMID: 23528678 DOI: 10.1016/j.resuscitation.2013.03.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 02/02/2013] [Accepted: 03/10/2013] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Prognostication of cardiac arrest survivors is challenging since therapeutic hypothermia (TH) has been introduced. We evaluated serum biomarkers and motor response. METHODS This was a retrospective data analysis including patients in the years 2007-2012. Blood was drawn and a neurological examination was performed on admission and every morning. Outcomes were evaluated 6 months after discharge and dichotomized into good (cerebral performance category (CPC)=1 or 2) and poor (CPC=3, 4 or 5). RESULTS 123 patients (79.7% male, 63±14 years) received TH; 50% had a good outcome. On admission, S-100B (P=0.004) was significantly associated with the outcome, as well as neuron-specific enolase (NSE; P=0.020) and S-100B (P=0.004) on day 1 after admission. NSE on day 2, NSE progression from day 1 to 2 and motor response on day 3 also predicted the outcome (all P<0.001). NSE>33μgl(-1) only predicted a poor outcome with a specificity of 76%. An absent motor response on day 3 was the most sensitive marker (94%). NSE>41.1μgl(-1) combined with S-100B>0.461μgl(-1) on day 1 was the most specific marker (96%). CONCLUSION Although NSE and S-100B levels are associated with the outcome, the use of previously described cut-off values was insufficiently predictive of neurologic outcome. Caution should be exercised in the use of these tests to provide neuroprognostication.
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Affiliation(s)
- T Zellner
- Intensive Care Unit, Medizinische Klinik Innenstadt (Ludwig-Maximilians-Universität), Munich, Germany.
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Thömke F. Assessing prognosis following cardiopulmonary resuscitation and therapeutic hypothermia-a critical discussion of recent studies. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:137-43. [PMID: 23533554 DOI: 10.3238/arztebl.2013.0137] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 11/06/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND The prognosis of patients who are comatose after cardiopulmonary resuscitation (CPR) is poor but can be improved by mild therapeutic hypothermia. We studied the question whether the known, reliable indicators of a poor prognosis after CPR are also valid for patients treated with CPR and hypothermia. METHODS This review is based on a selective search of the PubMed database for recent articles on the assessment of prognosis in persons who are comatose after CPR and therapeutic hypothermia. RESULTS On the basis of 21 clinical trials, 4 of which yielded level I evidence, 9 level II evidence, and 8 level III evidence, the following were identified as reliable indicators of a poor prognosis: generalized myoclonus, bilateral absence of the pupillary light response or of the corneal reflex, bilateral absence of the cortical components of median nerve somatosensory evoked potentials, a burst-suppression or isoelectric EEG, continuous generalized epileptiform discharges, and an elevated serum concentration of neuron-specific enolase (with a higher cutoff value than for normothermic patients). CONCLUSION If the prognosis is poor, this should be thoroughly discussed with the patient's family, and the nature and extent of further intensive treatment should be reconsidered. The patient's wishes, if known, are paramount. Any decision to withhold care should be taken only if there are multiple concurrent indicators of a poor prognosis. If only one such indicator is present, or if the findings are inconsistent, such decisions should be postponed.
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Affiliation(s)
- Frank Thömke
- University Medical Center of the Johannes Gutenberg University Mainz, Department of Neurology.
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Einav S, Kaufman N, Algur N, Kark JD. Modeling serum biomarkers S100 beta and neuron-specific enolase as predictors of outcome after out-of-hospital cardiac arrest: an aid to clinical decision making. J Am Coll Cardiol 2012; 60:304-11. [PMID: 22813607 DOI: 10.1016/j.jacc.2012.04.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 03/05/2012] [Accepted: 04/02/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this study was to determine the added value of the serum biomarkers S100 and neuron-specific enolase to clinical characteristics for predicting outcome after out-of-hospital cardiac arrest. BACKGROUND Serum S100 beta (S100B) and neuron-specific enolase concentrations rise after brain injury. METHODS A prolective observational study was conducted among all adult survivors of nontraumatic out-of-hospital cardiac arrest admitted to 1 hospital (April 3, 2008 to April 3, 2011). Three blood samples (on arrival and on days 1 and 3) were drawn for biomarkers, contingent on survival. Follow-up continued until in-hospital death or discharge. Outcomes were defined as good (Cerebral Performance Category score 1 or 2) or poor (Cerebral performance category score 3 to 5). RESULTS A total of 195 patients were included (65.6% men, mean age 73 ± 16 years), with presenting rhythms of asystole in 61.5% and ventricular tachycardia or ventricular fibrillation in 24.1%. Only 43 patients (22.0%) survived to hospital discharge, 26 (13.3%) with good outcomes. Patients with good outcomes had significantly lower S100B levels at all time points and lower neuron-specific enolase levels on days 1 and 3 compared with those with poor outcomes. Independent predictors at admission of a good outcome were younger age, a presenting rhythm of ventricular tachycardia or ventricular fibrillation, and lower S100B level. Predictors on day 3 were younger age and lower day 3 S100B level. The area under the receiver-operating characteristic curve of the admission-day model was 0.932 with and 0.880 without biomarker data (p = 0.027 for the difference). CONCLUSIONS Risk stratification after out-of-hospital cardiac arrest using both clinical and biomarker data is feasible. The biomarkers, although adding an ostensibly modest 5.2% to the area under the receiver-operating characteristic curve, substantially reduced the level of uncertainty in decision making. Nevertheless, current biomarkers cannot replace societal considerations in determining acceptable levels of uncertainty. (Protein S100 Beta as a Predictor of Resuscitation Outcome; NCT00814814).
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Abstract
Recent advances in medicine, intensive care and diagnostic imaging modalities have led to a pronounced reduction in deaths and disability resulting from traumatic brain injury. However, there are not sufficient findings to evaluate and quantify the severity of the initial and secondary processes destructive and therefore there are not effective therapeutic measures to effectively predict the outcome. For this reason, in recent decades, researchers and clinicians have focused on specific markers of cellular brain injury to improve the diagnosis and the evaluation of outcome. Many proteins synthesized in the astroglia cells or in the neurons, such as neuron-specific enolase, S100 calcium binding protein B, myelin basic protein, creatine kinase brain isoenzyme, glial fibrillary acidic protein, plasma desoxyribonucleic acid, brain-derived neurotrophic factor, and ubiquitin carboxy-terminal hydrolase-L1, have been proposed as potential markers for cell damage in central nervous system. Usually, the levels of these proteins increase following brain injury and are found in increasing concentrations in the cerebrospinal fluid depending on the injury magnitude, and can also be found in blood stream because of a compromised blood-brain barrier. In this review, we examine the various factors that must be taken into account in the search for a reliable non-invasive biomarkers in traumatic brain injury and their role in the diagnosis and outcome evaluation.
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Abstract
OBJECTIVES Determine the utility of the neurologic examination in comatose patients from nontraumatic causes in the modern era. DESIGN Prospective observational study. SETTING Single academic medical center. PATIENTS Data from 500 patients in nontraumatic coma collected sequentially from 2000 to 2007 in the emergency department and neuroscience, medical, and cardiac intensive care units. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical data were collected on days 0, 1, 3, and 7. Outcome was assessed at 6 months; good outcome was determined at two levels by modified Rankin Scale, ≤3 as independence and ≤4 as moderate but not severe disability. A classification and regression tree analysis was performed to determine prognostic variables, creating predictive algorithms of good vs. poor outcome for each day. Patients with coma attributable to subarachnoid hemorrhage (4/80; 5%) or global hypoxic-ischemic injury (20/202, 10%) were more likely to achieve good outcomes. The pupillary reflex was an important determinant, regardless of day or modified Rankin Scale cut point (mean odds ratio 12.51, range [6.01, 22.56] for modified Rankin Scale ≤3; mean odds ratio 19.26, range [5.38, 42.26] for modified Rankin Scale ≤4). A less robust effect was seen for oculocephalic reflexes (mean odds ratio 62.61, range [2.24, 177] for modified Rankin Scale ≤3; mean odds ratio 34.13, range [4.95, 89.93] for modified Rankin Scale ≤4). The motor response was selected as a predictor of outcome only on day 0 (odds ratio 2.35, 95% confidence interval 0.64-5.74 for modified Rankin Scale ≤3; odds ratio 2.1, 95% confidence interval 0.81-4.24 for modified Rankin Scale score ≤4). Age was not associated with outcome. CONCLUSIONS The clinical neurologic examination remains central to determining prognosis in nontraumatic coma. Additional clinical and diagnostic variables may also aid in outcome prediction for specific disease states.
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Stein DM, Lindell AL, Murdock KR, Kufera JA, Menaker J, Bochicchio GV, Aarabi B, Scalea TM. Use of serum biomarkers to predict cerebral hypoxia after severe traumatic brain injury. J Neurotrauma 2012; 29:1140-9. [PMID: 22360297 DOI: 10.1089/neu.2011.2149] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The management of severe traumatic brain injury (TBI) focuses on prevention and treatment of secondary insults such as cerebral hypoxia (CH). There are a number of biomarkers that are thought to play a part in secondary injury following severe TBI. This study evaluates the association between S100β, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP), detected in the serum of severe TBI patients and CH as measured by brain tissue oxygen partial pressure (Pbo(2)). Patients with severe TBI were prospectively enrolled. Pressure times time (PTD; mm Hg*h), measuring the depth and duration of CH, was calculated for 12-h periods for episodes of moderate (Pbo(2) < 20 mm Hg) and severe (Pbo(2) < 15 mm Hg) CH, and compared to serum levels of S100β, NSE, and GFAP drawn prior to periods of monitoring. An adjusted mixed model analysis was applied as was receiver operating characteristic (ROC) curve analysis. Of 76 patients enrolled, 24 had Pbo(2) monitoring. One hundred and thirty serum samples were matched with 12-h periods of monitoring. Significant associations were found in adjusted analyses between increasing serum levels of S100β (coefficient=0.57, 0.56; p<0.001), NSE (coefficient=0.48, 0.52; p<0.001), and GFAP (coefficient=0.29, 0.30; p=0.003 and 0.002), and increasing PTD of moderate (Pbo(2)<20 mm Hg) and severe (Pbo(2)<15 mm Hg) CH. AUCs for the prediction of moderate and severe CH were 0.62 and 0.66 for S100β, 0.55 and 0.71 for NSE, and 0.50 and 0.62 for GFAP, respectively. Specificities were between 76% and 90% for S100β and NSE. S100β, NSE, and GFAP demonstrate promise as candidate serum markers of impending CH. The fact that these biomarker elevations occur prior to the onset of clinical manifestations suggests that we may be able to predict imminent events following TBI. Given the morbidity of CH, early intervention and prevention may have a significant impact on outcomes and help guide decisions about the timing of interventions.
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Affiliation(s)
- Deborah M Stein
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Daubin C, Quentin C, Allouche S, Etard O, Gaillard C, Seguin A, Valette X, Parienti JJ, Prevost F, Ramakers M, Terzi N, Charbonneau P, du Cheyron D. Serum neuron-specific enolase as predictor of outcome in comatose cardiac-arrest survivors: a prospective cohort study. BMC Cardiovasc Disord 2011; 11:48. [PMID: 21824428 PMCID: PMC3161948 DOI: 10.1186/1471-2261-11-48] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 08/08/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prediction of neurological outcome in comatose patients after cardiac arrest has major ethical and socioeconomic implications. The purpose of this study was to assess the capability of serum neuron-specific enolase (NSE), a biomarker of hypoxic brain damage, to predict death or vegetative state in comatose cardiac-arrest survivors. METHODS We conducted a prospective observational cohort study in one university hospital and one general hospital Intensive Care Unit (ICU). All consecutive patients who suffered cardiac arrest and were subsequently admitted from June 2007 to February 2009 were considered for inclusion in the study. Patients who died or awoke within the first 48 hours of admission were excluded from the analysis. Patients were followed for 3 months or until death after cardiopulmonary resuscitation. The Cerebral Performance Categories scale (CPC) was used as the outcome measure; a CPC of 4-5 was regarded as a poor outcome, and a CPC of 1-3 a good outcome. Measurement of serum NSE was performed at 24 h and at 72 h after the time of cardiac arrest using an enzyme immunoassay. Clinicians were blinded to NSE results. RESULTS Ninety-seven patients were included. All patients were actively supported during the first days following cardiac arrest. Sixty-five patients (67%) underwent cooling after resuscitation. At 3 months 72 (74%) patients had a poor outcome (CPC 4-5) and 25 (26%) a good outcome (CPC 1-3). The median and Interquartile Range [IQR] levels of NSE at 24 h and at 72 h were significantly higher in patients with poor outcomes: NSE at 24 h: 59.4 ng/mL [37-106] versus 28.8 ng/mL [18-41] (p < 0.0001); and NSE at 72 h: 129.5 ng/mL [40-247] versus 15.7 ng/mL [12-19] (p < 0.0001). The Receiver Operator Characteristics (ROC) curve for poor outcome for the highest observed NSE value for each patient determined a cut-off value for NSE of 97 ng/mL to predict a poor neurological outcome with a specificity of 100% [95% CI = 87-100] and a sensitivity of 49% [95% CI = 37-60]. However, an approach based on a combination of SSEPs, NSE and clinical-EEG tests allowed to increase the number of patients (63/72 (88%)) identified as having a poor outcome and for whom intensive treatment could be regarded as futile. CONCLUSION NSE levels measured early in the course of patient care for those who remained comatose after cardiac arrest were significantly higher in patients with outcomes of death or vegetative state. In addition, we provide a cut-off value for NSE (> 97 ng/mL) with 100% positive predictive value of poor outcome. Nevertheless, for decisions concerning the continuation of treatment in this setting, we emphasize that an approach based on a combination of SSEPs, NSE and clinical EEG would be more accurate for identifying patients with a poor neurological outcome.
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Affiliation(s)
- Cédric Daubin
- Department of Medical Intensive Care, CHU de Caen, Caen, F-14000, France.
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European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2011; 81:1305-52. [PMID: 20956049 DOI: 10.1016/j.resuscitation.2010.08.017] [Citation(s) in RCA: 832] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Rana OR, Saygili E, Schiefer J, Marx N, Schauerte P. Biochemical markers and somatosensory evoked potentials in patients after cardiac arrest: the role of neurological outcome scores. J Neurol Sci 2011; 305:80-4. [PMID: 21440912 DOI: 10.1016/j.jns.2011.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 02/22/2011] [Accepted: 03/01/2011] [Indexed: 11/28/2022]
Abstract
Biochemical markers, e.g. NSE or S100B, and somatosensory evoked potentials (SSEP) are considered promising candidates for neurological prognostic predictors in patients after cardiac arrest (CA). The Utstein Templates recommend the use of the Glasgow-Pittsburgh Cerebral Performance Categories (GP-CPC) to divide patients according to their neurological outcome. However, several studies investigating biochemical markers and SSEP are based on the Glasgow Outcome Score (GOS). We noticed that many studies failed to exclude patients who died without certified brain damage from patients classified as poor outcome, instead including all patients who died into this category. Therefore, we summarized the published NSE cut-off values and the derived sensitivity and specificity to predict poor outcome of those studies which only included patients with certified brain death in GOS-1 or GP-CPC-5 (group A) vs. those studies which did not differentiate between death from any cause or death due to primary brain damage (group B). On average, mean NSE cut-off values and sensitivity were higher (56 ± 35 ng/ml, 56 ± 18%) in group A than in group B (41 ± 17 ng/ml, 44 ± 25%), respectively. The specificity remained equally high in both groups. In analogy, the average sensitivity of SSEP to predict poor outcome was higher in group A (76 ± 11%) than in group B (50 ± 15%), while the specificity was similar in both groups. Conclusively, inclusion of deaths without certified brain damage after CA in neurological outcome studies will lead to underestimation of the prognostic power of biochemical or electrophysiological markers for brain damage. A modified GOS and GP-CPC score might help to avoid this bias.
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Affiliation(s)
- Obaida R Rana
- Department of Cardiology, RWTH Aachen University, Aachen, Germany.
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Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e93-e174. [PMID: 20956032 DOI: 10.1016/j.resuscitation.2010.08.027] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Sarpaczki E, Bertram M, Grüttner J, Brandt T. [Patient in a posthypoxic vegetative state. Favorable outcome despite unfavorable prognostic parameters]. DER NERVENARZT 2010; 81:1504-1507. [PMID: 21088820 DOI: 10.1007/s00115-010-3107-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- E Sarpaczki
- Kliniken Schmieder Heidelberg, Neurologisches Fach- und Rehabilitationskrankenhaus, Heidelberg, Speyererhofweg 1, 69117, Heidelberg.
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Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, Vanden Hoek TL, Kronick SL. Part 9: Post–Cardiac Arrest Care. Circulation 2010; 122:S768-86. [DOI: 10.1161/circulationaha.110.971002] [Citation(s) in RCA: 1034] [Impact Index Per Article: 73.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Continuous amplitude-integrated electroencephalogram predicts outcome in hypothermia-treated cardiac arrest patients. Crit Care Med 2010; 38:1838-44. [PMID: 20562694 DOI: 10.1097/ccm.0b013e3181eaa1e7] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the prognostic value of continuous amplitude-integrated electroencephalogram in comatose survivors after cardiac arrest and treated with hypothermia. DESIGN Prospective observational study. SETTING General intensive care unit at a university hospital. PATIENTS Comatose patients after cardiac arrest and treated with hypothermia. INTERVENTIONS Patients were sedated and continuously monitored using an amplitude-integrated electroencephalogram. Monitoring was commenced on arrival in the intensive care unit and continued until recovery of consciousness, death, or 120 hrs after cardiac arrest. The amplitude-integrated electroencephalogram was interpreted together with the original electroencephalogram and analyzed without knowledge of the patient's clinical status. The amplitude-integrated electroencephalogram patterns at start of registration and at normothermia and the transitions of the amplitude-integrated electroencephalogram patterns over time were correlated to outcome. MEASUREMENTS AND MAIN RESULTS A total of 111 consecutive patients were assessed; 11 patients were not included because of technical reasons and five were excluded because of death before normothermia. Ninety-five patients remained; 57 (60%) eventually regained consciousness, of whom 49 (52%) lived an independent life at 6 months. Thirty-one patients (33%) at start of registration and 62 patients (65%) at normothermia had a continuous electroencephalogram pattern, and this was strongly associated with recovery of consciousness (29/31 [90%] and 54/62 [87%]). A suppression-burst pattern was always transient and patients with suppression-burst at any time remained in coma until death. An initial flat pattern was registered in 47 patients, but this had no prognostic value. Electrographic status epilepticus was a common finding (26/95 patients [27%]) and two types of electrographic status epilepticus were identified: one developed from suppression-burst and one developed from a continuous background. Two patients from the latter group regained consciousness. CONCLUSIONS Continuous amplitude-integrated electroencephalogram adds valuable early positive and negative prognostic information in comatose survivors after cardiac arrest. We identified two types of postanoxic electrographic status epilepticus, which is a novel finding with possible therapeutic implications.
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Berger RP, Bazaco MC, Wagner AK, Kochanek PM, Fabio A. Trajectory analysis of serum biomarker concentrations facilitates outcome prediction after pediatric traumatic and hypoxemic brain injury. Dev Neurosci 2010; 32:396-405. [PMID: 20847541 DOI: 10.1159/000316803] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 06/07/2010] [Indexed: 11/19/2022] Open
Abstract
Traumatic brain injury (TBI) and hypoxic ischemic encephalopathy (HIE) are leading causes of morbidity and mortality in children. Several studies over the past several years have evaluated the use of serum biomarkers to predict outcome after pediatric brain injury. These studies have all used simple point estimates such as initial and peak biomarker concentrations to predict outcome. However, this approach does not recognize patterns of change over time. Trajectory analysis is a type of analysis which can capture variance in biomarker concentrations over time and has been used with success in the social sciences. We used trajectory analysis to evaluate the ability of the serum concentrations of 3 brain-specific biomarkers - S100B, neuron-specific enolase (NSE) and myelin basic protein (MBP) - to predict poor outcome (Glasgow Outcome Scale scores 3-5) after pediatric TBI and HIE. Clinical and biomarker data from 100 children with TBI or HIE were evaluated. For each biomarker, we validated 2-, 3- and 4-group models for outcome prediction, using sensitivity and specificity. For S100B, the 3-group model predicted poor outcome with a sensitivity of 59% and specificity of 100%. For NSE, the 3-group model predicted poor outcome with a sensitivity of 48% and specificity of 98%. For MBP, the 3-group model predicted poor outcome with a sensitivity of 73% and specificity of 61%. Thus, when the models predicted a poor outcome, there was a very high probability of a poor outcome. In contrast, 17% of subjects with a poor outcome were predicted to have a good outcome by all 3 biomarker trajectories. These data suggest that trajectory analysis of biomarker data may provide a useful approach for predicting outcome after pediatric brain injury.
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Affiliation(s)
- Rachel Pardes Berger
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Safar Center for Resuscitation Research, Pittsburgh, PA 15227, USA.
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Steffen IG, Hasper D, Ploner CJ, Schefold JC, Dietz E, Martens F, Nee J, Krueger A, Jörres A, Storm C. Mild therapeutic hypothermia alters neuron specific enolase as an outcome predictor after resuscitation: 97 prospective hypothermia patients compared to 133 historical non-hypothermia patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R69. [PMID: 20403168 PMCID: PMC2887191 DOI: 10.1186/cc8975] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 03/22/2010] [Accepted: 04/19/2010] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Neuron specific enolase (NSE) has been proven effective in predicting neurological outcome after cardiac arrest with a current cut off recommendation of 33 microg/l. However, most of the corresponding studies were conducted before the introduction of mild therapeutic hypothermia (MTH). Therefore we conducted a study investigating the association between NSE and neurological outcome in patients treated with MTH. METHODS In this prospective observational cohort study the data of patients after cardiac arrest receiving MTH (n = 97) were consecutively collected and compared with a retrospective non-hypothermia (NH) group (n = 133). Serum NSE was measured 72 hours after admission to ICU. Neurological outcome was classified according to the Pittsburgh cerebral performance category (CPC 1 to 5) at ICU discharge. RESULTS NSE serum levels were significantly lower under MTH compared to NH in univariate analysis. However, in a linear regression model NSE was affected significantly by time to return of spontaneous circulation (ROSC) and ventricular fibrillation rhythm but not by MTH. The model for neurological outcome identified NSE, NSE*MTH (interaction) as well as time to ROSC as significant predictors. Receiver Operating Characteristic (ROC) analysis revealed a higher cutoff value for unfavourable outcome (CPC 3 to 5) with a specificity of 100% in the hypothermia group (78.9 microg/l) compared to the NH group (26.9 microg/l). CONCLUSIONS Recommended cutoff levels for NSE 72 hours after ROSC do not reliably predict poor neurological outcome in cardiac arrest patients treated with MTH. Prospective multicentre trials are required to re-evaluate NSE cutoff values for the prediction of neurological outcome in patients treated with MTH.
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Affiliation(s)
- Ingo G Steffen
- Department of Nephrology and Medical Intensive Care Medicine, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburgerplatz 1, Berlin, Germany.
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Abstract
BACKGROUND Neurologists are frequently called to evaluate patients in the intensive care units who are not waking up. This often poses a diagnostic and prognostic dilemma. REVIEW SUMMARY The initial evaluation starts with abstracting the prehospital and in-hospital history, followed by bedside clinical and neurologic examination to establish a differential diagnosis. The subsequent work-up is based on clinical suspicion where reversible life-threatening causes should be immediately identified. After confirming the diagnosis and implementation of the appropriate medical management, a prompt family meeting and counseling is recommended. The role of neurologists in clinical diagnosis and prognostication of the coma patient, as well as diagnosing brain death is instrumental. CONCLUSIONS In this review, we explore a practical systematic approach to patients with decreased level of consciousness. The most common causes of impaired alertness in different non-neurologic critical care units and commonly used prognostication tools are presented. Finally a brief introduction of hypothermia, a novel therapeutic approach is also discussed.
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Hasper D, von Haehling S, Storm C, Jörres A, Schefold JC. Changes in serum creatinine in the first 24 hours after cardiac arrest indicate prognosis: an observational cohort study. Crit Care 2009; 13:R168. [PMID: 19874577 PMCID: PMC2784400 DOI: 10.1186/cc8144] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 09/22/2009] [Accepted: 10/29/2009] [Indexed: 03/16/2023] Open
Abstract
Introduction As patients after cardiac arrest suffer from the consequences of global ischemia reperfusion, we aimed to establish the incidence of acute kidney injury (AKI) in these patients, and to investigate its possible association to severe hypoxic brain damage. Methods One hundred and seventy-one patients (135 male, mean age 61.6 +/- 15.0 years) after cardiac arrest were included in an observational cohort study. Serum creatinine was determined at admission and 24, 48 and 72 hours thereafter. Serum levels of neuron-specific enolase (NSE) were measured 72 hours after admission as a marker of hypoxic brain damage. Clinical outcome was assessed at intensive care unit (ICU) discharge using the Pittsburgh cerebral performance category (CPC). Results AKI as defined by AKI Network criteria occurred in 49% of the study patients. Patients with an unfavourable prognosis (CPC 3-5) were affected significantly more frequently (P = 0.013). Whilst serum creatinine levels decreased in patients with good neurological outcome (CPC 1 or 2) over the ensuing 48 hours, it increased in patients with unfavourable outcome (CPC 3-5). ROC analysis identified DeltaCrea24 <-0.19 mg/dl as the value for prediction with the highest accuracy. The odds ratio for an unfavourable outcome was 3.81 (95% CI 1.98-7.33, P = 0.0001) in cases of unchanged or increased creatinine levels after 24 hours compared to those whose creatinine levels decreased during the first 24 hours. NSE levels were found to correlate with the change in serum creatinine in the first 24 hours both in simple and multivariate regression (both r = 0.24, P = 0.002). Conclusions In this large cohort of patient after cardiac arrest, we found that AKI occurs in nearly 50% of patients when the new criteria are applied. Patients with unfavourable neurological outcome are affected more frequently. A significant association between the development of AKI and NSE levels indicating hypoxic brain damage was observed. Our data show that changes in serum creatinine may contribute to the prediction of outcome in patients with cardiac arrest. Whereas a decline in serum creatinine (> 0.2 mg/dL) in the first 24 hours after cardiac arrest indicates good prognosis, the risk of unfavourable outcome is markedly elevated in patients with constant or increasing serum creatinine.
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Affiliation(s)
- Dietrich Hasper
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany.
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Turedi S, Gunduz A, Mentese A, Dasdibi B, Karahan SC, Sahin A, Tuten G, Kopuz M, Alver A. Investigation of the possibility of using ischemia-modified albumin as a novel and early prognostic marker in cardiac arrest patients after cardiopulmonary resuscitation. Resuscitation 2009; 80:994-9. [DOI: 10.1016/j.resuscitation.2009.06.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Revised: 06/03/2009] [Accepted: 06/06/2009] [Indexed: 12/20/2022]
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