Clinical targeting of the cerebral oxygen cascade to improve brain oxygenation in patients with hypoxic-ischaemic brain injury after cardiac arrest

Nanoparticle-mediated sodium butyrate delivery for repairing hypoxic-ischemic brain injury in premature infants

Hypoxic-ischemic encephalopathy of prematurity (HIEP) is a leading cause of acute mortality and chronic neurological injury in premature infants. This study investigates the molecular mechanisms by which magnetic fluorescent nanoparticles loaded with sodium butyrate (MNs@SB) repair HIEP by modulating the Sp1 and TGF-β1 signaling pathways. Untargeted metabolomics analysis revealed significant suppression of the butyrate metabolism pathway in the intestinal tissues of HIEP mice. We synthesized and characterized MNs@SB nanoparticles, with zeta potential and DLS results indicating an average nanoparticle size of approximately 79.89 nm and a zeta potential of -36.87 mV. TEM images confirmed that the nanoparticles formed polymer-coated clusters. MNs@SB demonstrated excellent biocompatibility and stable magnetic targeting behavior. The nanoparticles were delivered to the brain via tail vein injection and magnetic targeting, with focused ultrasound facilitating their diffusion. The results showed that HIEP mice exhibited a significant increase in infarct size and extensive tissue loss, whereas MNs@SB treatment effectively reversed HIEP-induced brain damage, improving both short-term and long-term neurological deficits. Single-cell RNA sequencing and high-throughput transcriptome analysis revealed that MNs@SB promoted brain repair by upregulating neuronal Sp1, activating the TGF-β1 signaling pathway, and inhibiting neuronal apoptosis. In vivo experiments further confirmed that MNs@SB treatment restored SP1 mRNA and protein expression in the brain. Additionally, MNs@SB treatment significantly restored TGF-β1, p-SMAD2, and p-SMAD3 protein expression, indicating activation of the TGF-β1/SMAD2/3 signaling pathway. This study presents a novel nanomedicine therapeutic strategy with potential clinical applications.

Postresuscitation pleth variability index-guided hemodynamic management of out-of-hospital cardiac arrest survivors: A randomised controlled trial

Background and purpose

Hypotension and shock after return of spontaneous circulation is harmful. Goal-directed post-resuscitation care aims at maintaining adequate perfusion pressure, but evidence.on strategies to achieve this goal is limited. This study aimed to compare outcomes of pleth variability index (PVi) supported hemodynamic management during early hospital admission with those of standard hemodynamic management.

Methods and trial design

From March 2019 to August 2023, all mechanically ventilated patients adults admitted alive after a non-traumatic out-of-hospital cardiac arrest (OHCA) to the emergency department of Saint-Pierre University Hospital in Brussels, were screened for inclusion in this prospective, parallel, randomised, single-blind study. We enrolled patients with signs of tissue hypoperfusion after cardiac arrest. Patients were randomly allocated (1:1) to undergo hemodynamic treatment based on the PVi (intervention) or standard monitoring (control). Hemodynamic interventions targeted mean blood pressure above 70 mmHg, a capillary refill time below 3 s and urine output above 0.5 ml/kg/minute. The primary outcome was lactate clearance at 3 h. We hypothesized that PVi guided hemodynamic management would result in a faster lactate clearance at 3 h.

Results

96 patients underwent randomization. Due to non-consent and loss to follow-up 82 patients were included in the analysis, 39 in the intervention and 43 in the control group. The median lactate clearance 3 h after inclusion was not different between groups (57.4% [Interquartile range (IQR): 27.7-75.8%] in the control group versus 61.5% [IQR: 39.3-74.7%] in the intervention group), with a mean difference of 4.9% (95% CI, -7.5-17.2; p = 0.44) between the two groups. No side effects were observed.

Conclusion

A pleth variability index-based protocol did not significantly improve the lactate clearance compared with standard care (NCT03841708).

Acetyl-CoA synthetase 2 alleviates brain injury following cardiac arrest by promoting autophagy in brain microvascular endothelial cells

INTRODUCTION

Brain injury is a common sequela following cardiac arrest (CA), with up to 70% of hospitalized patients dying from it. Brain microvascular endothelial cells (BMVECs) play a crucial role in post-cardiac arrest brain injury (PCABI). However, the effects and mechanisms of targeting BMVEC energy metabolism to mitigate brain injury remain unclear.

METHODS

We established a mouse model of cardiac arrest by injecting potassium chloride into the right internal jugular vein. Mass spectrometry detected targeted changes in short-chain fatty acids and energy metabolism metabolites in the CA/CPR group compared to the sham group. Mice with overexpressed ACSS2 in BMVECs were created using an AAV-BR1 vector, and ACSS2 knockout mice were generated using the CRE-LOXP system. The oxygen glucose deprivation/re-oxygenation (OGD/R) model was established to investigate the role and mechanisms of ACSS2 in endothelial cells in vitro.

RESULTS

Metabolomics analysis revealed disrupted cerebral energy metabolism post-CA/CPR, with decreased acetyl-CoA and amino acids. Overexpression of ACSS2 in BMVECs increased acetyl-CoA levels and improved neurological function. Vascular endothelial cell-specific ACSS2 knockout mice exhibited reduced aortic sprouting in vitro. Overexpression of ACSS2 improved endothelial dysfunction following oxygen glucose deprivation/re-oxygenation (OGD/R) and influenced autophagy by interacting with transcription factor EB (TFEB) and modulating the AMP-activated protein kinase α (AMPKα) pathway.

CONCLUSION

Our study shows that ACSS2 modulates the biological functions of BMVECs by promoting autophagy. Enhancing energy metabolism via ACSS2 may target PCABI treatment development.

Unlocking the potential of high-resolution multimodality neuromonitoring for traumatic brain injury management: lessons and insights from cases, events, and patterns

Multimodality neuromonitoring represents a crucial cornerstone for patient management after acute brain injury. Despite the potential of multimodality neuromonitoring (particularly high-resolution neuromonitoring data) to transform care, its full benefits are not yet universally realized. There remains a critical need to integrate the interpretation of complex patterns and indices into the real-time clinical decision-making processes. This requires a multidisciplinary approach, to evaluate and discuss the implications of observed patterns in a timely manner, ideally in close temporal proximity to their occurrence. Such a collaborative effort could enable clinicians to harness the full potential of multimodal data. In this educational case-based scoping review, we aim to provide clinicians, researchers, and healthcare professionals with detailed, compelling examples of potential applications of multimodality neuromonitoring, focused on high-resolution modalities within the field of traumatic brain injury. This case series showcases how neuromonitoring modalities such as intracranial pressure, brain tissue oxygenation, near-infrared spectroscopy, and transcranial Doppler can be integrated with cerebral microdialysis, neuroimaging and systemic physiology monitoring. The aim is to demonstrate the value of a multimodal approach based on high-resolution data and derived indices integrated in one monitoring tool, allowing for the improvement of diagnosis, monitoring, and treatment of patients with traumatic brain injury. For this purpose, key concepts are covered, and various cases have been described to illustrate how to make the most of this advanced monitoring technology.

Development of hemoglobin microbubbles for acoustic blood oxygen sensing: A study on PEGylation and gas core modification for in vivo applications

The creation of innovative ultrasound contrast agents (UCAs) with the ability to monitor oxygen levels in real-time holds immense potential for advancing early diagnosis of various medical conditions such as hypoxic/reperfusion injury. In this study, we propose the development of oxygen sensitive UCAs using microbubbles composed of hemoglobin (HbMBs), which can function as sensors for blood oxygen levels. Previously, we performed a study highlighting the initial proof-of-concept efficacy of air-filled HbMBs in detecting oxygenation changes in vitro, offering a promising tool for clinically detecting tissue hypoxia. Nevertheless, a significant drawback of this approach is the potential for immune reactions and toxicity when hemoglobin is outside its natural red blood cell environment. Moreover, in vitro, HbMBs had low stability, with more than 90% decrease in their concentration after 120 minutes. Therefore, careful consideration of the surface properties and the gas core of HbMBs is crucial. Here, we formulated PEGylated HbMBs (PHbMBs), and investigated their stability, immunogenicity, and their acoustic response in oxygenated and deoxygenated media in vitro. We optimized PEGylated HbMBs (PHbMBs), showing a 42% reduction in immunogenicity and significantly improved stability in vitro, while maintaining their oxygen-binding and acoustic response. In vivo, PHbMBs demonstrated similar contrast enhancement to that of non-PEGylated MBs, demonstrating that PEGylation does not decrease HbMBs' acoustic signaling. Finally, changing the gas core from air to PFB increased PHbMBs' mean circulation time more than 11-fold, without diminishing their responsiveness to oxygen. Overall, the proposed oxygen sensitive PHbMBs offer a promising avenue for real-time acoustic detection of blood oxygen levels, paving the way for potential clinical applications in monitoring critically ill patients. STATEMENT OF SIGNIFICANCE: This research explores the emergent field of Acoustic Oxygen Imaging in vivo using hemoglobin-based microbubbles. This innovative contrast agent approach involves imaging using crosslinked biomaterial comprised of the hemoglobin protein, aiming to transform the way we monitor blood oxygen levels with ultrasound. This work fundamentally addresses central concerns of improving bubble stability and circulation life for eventual clinical use, while minimizing toxicity. Importantly, we demonstrate that PEGylation of hemoglobin microbubbles enhances their stability, reduces immunogenicity, and maintains acoustic responsiveness. The incorporation of perfluorobutane into the bubble core increases the longevity of these microbubbles in circulation, while sustaining their oxygen sensitivity. Favorable in vivo results highlight the potential of this technology in real-time acoustic detection of blood oxygen levels.

Application of high-quality targeted temperature management guided by multimodal brain monitoring in brain protection of patients with cardiac arrest: A case series

RATIONALE

Cardiac arrest (CA) is an acute emergency with high mortality and is closely associated with the risk of brain damage or systemic ischemia-reperfusion injury, post-traumatic stress symptoms.

PATIENT CONCERNS

Targeted temperature management in the intensive care unit can improve the neurological outcomes of patients who are comatose after resuscitation from CA. However, there is often a lack of specific evaluation methods for optimal target temperature settings.

DIAGNOSES

From November 2021 to October 2022, 9 CA patients received prompt cardiopulmonary resuscitation and return of spontaneous circulation after approximately 10 to 30 minutes of cardiopulmonary resuscitation in Xiangya Hospital, Central South University.

INTERVENTIONS

We retrospectively reviewed 9 CA patients' medical data, including demographic characteristics, hemodynamic change, clinically relevant score, imageological examination, transcranial Doppler ultrasonography, electroencephalogram (EEG), somatosensory-evoked potential, and laboratory data.

OUTCOMES

According to the result of each patient's transcranial Doppler ultrasonography, somatosensory-evoked potential, and EEG to formulate an individualized target temperature. Contrary to the internationally recommended target of hypothermia, we found that not all patients require hypothermia therapy to maintain normal cerebrovascular autonomic regulation function. And neuron-specific enolase and S100β in patients showed a downward trend after hypothermia therapy. Compared with before hypothermia treatment, clinically relevant scores were reduced in patients with good prognosis. Intracranial congestion or ischemia was improved and intracranial pressure was reduced in all patients during hypothermia treatment. For patients with good EEG response, the ratio of gray matter in the brain increased and the neurological prognosis was significantly improved. Finally, after 6 months of follow-up, we found 3 patients died and 1 patient had a long-term vegetative state, the other patients had a good prognosis.

LESSONS

Individualized targeted temperature management under the guidance of multimodal brain monitoring plays an important role in brain protection of patients with CA.

Cerebral capillary oxygen diffusion: exploring the concept of intracapillary hemoglobin conformational changes

The mechanisms of oxygen diffusion in brain capillaries have not been fully clarified to date. According to the laws of physics, the well-documented phenomenon of hyperoxemia-induced excessive increases in brain tissue oxygen pressure (PbtO2) contradicts traditional models of cerebral capillary oxygen diffusion. Circulating models predict a significant drop in oxygen pressure (PO2), and some of them foresee the presence of hypoxic or anoxic corners near the capillary end, regardless of high PbtO2 levels. We propose that the cerebral intracapillary transformation of hemoglobin from the relaxed (R) to the tense (T) quaternary conformational state, driven by deoxygenation and an overload of negative allosteric effectors, and characterized by a lower, more hyperbolic dissociation curve, mitigates the oxygen pressure difference across cerebral capillaries, ensuring a homogeneous pericapillary distribution of oxygen. The hemoglobin R to T state transition is responsible for the high PbtO2 levels observed in viable cerebral tissue during hyperoxemia.

Oxygen Delivery and Consumption in Patients Who Are Comatose After Out-of-Hospital Cardiac Arrest Are Affected by Blood Pressure Target

BACKGROUND

In the management of patients resuscitated from out-of-hospital cardiac arrest, a primary goal is to restore sufficient oxygen delivery (DO2) to meet demands in oxygen consumption (VO2).

METHODS AND RESULTS

This post hoc analysis of the BOX (Blood Pressure and Oxygen Targets) study included adult patients who were comatose and experienced out-of-hospital cardiac arrest from a presumed cardiac cause, who were randomized to a mean arterial blood pressure (MAP) target of 63 mm Hg (MAP63) or 77 mm Hg (MAP77) and a Restrictive PaO2 target of 9 to 10 kPa versus a Liberal target of 13 to 14 kPa in a 2×2 factorial design. A pulmonary artery catheter was inserted following randomization. DO2 and VO2 were calculated as: DO2=cardiac output × arterial oxygen content, and VO2= cardiac output × arteriovenous oxygen difference. Of 789 patients, 730 (92.5%) were included in this substudy. A total of 362 patients were randomized to MAP77, and 368 to MAP63, 368 to a liberal Pao2 target, and 362 to a restrictive target. At all prespecified time points, DO2 in MAP77 was higher compared with MAP63, with a cumulative treatment effect of 203 L (95% CI, 132-274) O2 after 36 hours. VO2 was higher in MAP77 after 36 hours, with a cumulative treatment effect of 21.9 L (95% CI, 5.8-38) O2, compared with the MAP63 group.

CONCLUSIONS

Targeting a MAP of 77 mm Hg resulted in an overall increase in DO2 and a smaller increase in VO2 compared with a MAP target of 63 mm Hg. A higher Pao2 target did not result in any difference in DO2 or VO2.

The role of TRAP1 in regulating mitochondrial dynamics during acute hypoxia-induced brain injury

Brain damage caused by acute hypoxia is associated with the physiological activities of mitochondria. Although mitochondria being dynamically regulated, our comprehensive understanding of the response of specific brain cell types to acute hypoxia remains ambiguous. Tumor necrosis factor receptor-associated protein 1 (TRAP1), a mitochondrial-based molecular chaperone, plays a role in controlling mitochondrial movements. Herein, we demonstrated that acute hypoxia significantly alters mitochondria morphology and functionality in both in vivo and in vitro brain injury experiments. Summary-data-based Mendelian Randomization (SMR) analyses revealed possible causative links between mitochondria-related genes and hypoxia injury. Advancing the protein-protein interaction network and molecular docking further elucidated the associations between TRAP1 and mitochondrial dynamics. Furthermore, it was shown that TRAP1 knockdown levels variably affected the expression of key mitochondrial dynamics proteins (DRP1, FIS1, and MFN1/2) in primary hippocampal neurons, astrocytes, and BV-2 cell, leading to changes in mitochondrial structure and function. Understanding the function of TRAP1 in altering mitochondrial physiological activity during hypoxia-induced acute brain injury could help serve as a potential therapeutic target to mitigate neurological damage.

Prognostic performance of gray-white matter ratio in adult out-of-hospital cardiac arrest patients after receiving extracorporeal cardiopulmonary resuscitation

BACKGROUND

Gray-to-white matter ratio (GWR), measured by computed tomography (CT), is commonly used to predict poor neurological outcomes after out-of-hospital cardiac arrest (OHCA). The prognostic performance of GWR in OHCA patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) is not known.

METHODS

This study is a secondary analysis of data from the SAVE-J II registry, a retrospective, multicenter study. Participants were divided into four groups according to average GWR (aGWR) values ranging from 1.00 to 1.39, separated by 0.1 intervals. The aGWR values were calculated for bilateral basal ganglia, centrum semiovale, and high convexity obtained by head CT within 24 h after ECPR. Primary outcome was poor neurological outcomes at 30-day.

RESULTS

In total, 1,146 OHCA patients treated with ECPR were included in our analysis. Overall, participants with lower aGWR more likely had poor neurological outcomes, aGWR 1.00-1.09 (94.6%), aGWR 1.10-1-19 (87.8%), aGWR 1.20-1.29 (78.5%), and aGWR 1.30-1.39 (70.3%). Multivariable logistic regression showed that lower aGWR was associated with poor neurological outcome at 30-day, aGWR 1.30-1.39: reference, aGWR 1.00-1.09: adjusted odds ratio (aOR) 10.01 (95% confidence interval (CI) [3.58-27.99]), aGWR 1.10-1.19: aOR 4.83 (95% CI [2.31-10.12]), aGWR 1.20-1.29: aOR 2.16 (95% CI [1.02-4.55]). Receiver operating characteristic curve analysis revealed that the prognostic performance of aGWR had an area under the curve of 0.628, 95% CI [0.59-0.66]). The aGWR threshold of 1.005 for predicting poor neurological outcome reached 100% specificity with 0.1% sensitivity.

CONCLUSION

Early neuro-prognostication depending on GWR may not be sufficient after ECPR and requires a multimodal approach.

Vascular Impairment, Muscle Atrophy, and Cognitive Decline: Critical Age-Related Conditions

The triad of vascular impairment, muscle atrophy, and cognitive decline represents critical age-related conditions that significantly impact health. Vascular impairment disrupts blood flow, precipitating the muscle mass reduction seen in sarcopenia and the decline in neuronal function characteristic of neurodegeneration. Our limited understanding of the intricate relationships within this triad hinders accurate diagnosis and effective treatment strategies. This review analyzes the interrelated mechanisms that contribute to these conditions, with a specific focus on oxidative stress, chronic inflammation, and impaired nutrient delivery. The aim is to understand the common pathways involved and to suggest comprehensive therapeutic approaches. Vascular dysfunctions hinder the circulation of blood and the transportation of nutrients, resulting in sarcopenia characterized by muscle atrophy and weakness. Vascular dysfunction and sarcopenia have a negative impact on physical function and quality of life. Neurodegenerative diseases exhibit comparable pathophysiological mechanisms that affect cognitive and motor functions. Preventive and therapeutic approaches encompass lifestyle adjustments, addressing oxidative stress, inflammation, and integrated therapies that focus on improving vascular and muscular well-being. Better understanding of these links can refine therapeutic strategies and yield better patient outcomes. This study emphasizes the complex interplay between vascular dysfunction, muscle degeneration, and cognitive decline, highlighting the necessity for multidisciplinary treatment approaches. Advances in this domain promise improved diagnostic accuracy, more effective therapeutic options, and enhanced preventive measures, all contributing to a higher quality of life for the elderly population.

Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know

Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.

Cerebral perfusion and metabolism with mild hypercapnia vs. normocapnia in a porcine post cardiac arrest model with and without targeted temperature management

Aim

To determine whether targeting mild hypercapnia (PaCO2 7 kPa) would yield improved cerebral blood flow and metabolism compared to normocapnia (PaCO2 5 kPa) with and without targeted temperature management to 33 °C (TTM33) in a porcine post-cardiac arrest model.

Methods

39 pigs were resuscitated after 10 minutes of cardiac arrest using cardiopulmonary bypass and randomised to TTM33 or no-TTM, and hypercapnia or normocapnia. TTM33 was managed with intravasal cooling. Animals were stabilized for 30 minutes followed by a two-hour intervention period. Hemodynamic parameters were measured continuously, and neuromonitoring included intracranial pressure (ICP), pressure reactivity index, cerebral blood flow, brain-tissue pCO2 and microdialysis. Measurements are reported as proportion of baseline, and areas under the curve during the 120 min intervention period were compared.

Results

Hypercapnia increased cerebral flow in both TTM33 and no-TTM groups, but also increased ICP (199% vs. 183% of baseline, p = 0.018) and reduced cerebral perfusion pressure (70% vs. 84% of baseline, p < 0.001) in no-TTM animals. Cerebral lactate (196% vs. 297% of baseline, p < 0.001), pyruvate (118% vs. 152% of baseline, p < 0.001), glycerol and lactate/pyruvate ratios were lower with hypercapnia in the TTM33 group, but only pyruvate (133% vs. 150% of baseline, p = 0.002) was lower with hypercapnia among no-TTM animals.

Conclusion

In this porcine post-arrest model, hypercapnia led to increased cerebral flow both with and without hypothermia, but also increased ICP and reduced cerebral perfusion pressure in no-TTM animals. The effects of hypercapnia were different with and without TTM.(Institutional protocol number: FOTS, id 14931).

Shining a light on cerebral autoregulation: Are we anywhere near the truth?

The near-infrared spectroscopy (NIRS)-derived cerebral oximetry index (COx) has become popularized for non-invasive neuromonitoring of cerebrovascular function in post-cardiac arrest patients with hypoxic-ischemic brain injury (HIBI). We provide commentary on the physiologic underpinnings and assumptions of NIRS and the COx, potential confounds in the context of HIBI, and the implications for the assessment of cerebral autoregulation.

Mechanisms and treatment of anemia related to cardiac arrest

Cardiac arrest is a common and fatal emergency situation. Recently, an increasing number of studies have shown that anemia in patients with cardiac arrest is closely related to high mortality rates and poor neurological outcomes. Anemia is prevalent among patients with post-cardiac arrest syndrome (PCAS), but its specific pathogenesis remains unclear. The mechanisms may involve various factors, including reduced production of erythropoietin, oxidative stress/inflammatory responses, gastrointestinal ischemic injury, hepcidin abnormalities, iatrogenic blood loss, and malnutrition. Measures to improve anemia related to cardiac arrest may include blood transfusions, administration of erythropoietin, anti-inflammation and antioxidant therapies, supplementation of hematopoietic materials, protection of gastrointestinal mucosa, and use of hepcidin antibodies and antagonists. Therefore, exploring the latest research progress on the mechanisms and treatment of anemia related to cardiac arrest is of significant guiding importance for improving secondary brain injury caused by anemia and the prognosis of patients with cardiac arrest.

Light-activated g-C3N4 photoelectrodes with a selective molecular sieve for in vivo quantification of oxygen levels in the living mouse brain

A novel micro-photoelectrode with a selective molecular sieve was created for in vivo monitoring of O2 levels in the mouse brain. An ITO optical fiber modified by graphitized carbon nitride (g-C3N4) in situ was employed as the light activated substrate to provide rich photo-induced electrons for the catalytic reduction of O2. Meanwhile, the porous hybrid layer composed of zeolitic imidazolate framework-8 and polysulfone was constructed over the g-C3N4 surface as the molecular sieve to synergically enhance the selectivity of O2 detections. By advantage of this useful tool, the real time variation of the O2 level was successfully determined in the mouse brain upon ischemia.

Wolf Creek XVII Part 8: Neuroprotection

Introduction

Post-cardiac arrest brain injury (PCABI) is the primary determinant of clinical outcomes for patients who achieve return of spontaneous circulation after cardiac arrest (CA). There are limited neuroprotective therapies available to mitigate the acute pathophysiology of PCABI.

Methods

Neuroprotection was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of CA resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation, and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised and ranked by all attendees to identify the top 5 for each category.

Results

Top 5 knowledge gaps included developing therapies for neuroprotection; improving understanding of the pathophysiology, mechanisms, and natural history of PCABI; deploying precision medicine approaches; optimizing resuscitation and CPR quality; and determining optimal timing for and duration of interventions. Top 5 barriers to translation included patient heterogeneity; nihilism & lack of knowledge about cardiac arrest; challenges with the translational pipeline; absence of mechanistic biomarkers; and inaccurate neuro-triage and neuroprognostication. Top 5 research priorities focused on translational research and trial optimization; addressing patient heterogeneity and individualized interventions; improving understanding of pathophysiology and mechanisms; developing mechanistic and outcome biomarkers across post-CA time course; and improving implementation of science and technology.

Conclusion

This overview can serve as a guide to transform the care and outcome of patients with PCABI. Addressing these topics has the potential to improve both research and clinical care in the field of neuroprotection for PCABI.