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Bougouin W, Lascarrou JB, Chelly J, Benghanem S, Geri G, Maizel J, Fage N, Sboui G, Pichon N, Daubin C, Sauneuf B, Mongardon N, Taccone F, Hermann B, Colin G, Lesieur O, Deye N, Chudeau N, Cour M, Bourenne J, Klouche K, Klein T, Raphalen JH, Muller G, Galbois A, Bruel C, Jacquier S, Paul M, Sandroni C, Cariou A. Performance of the ERC/ESICM-recommendations for neuroprognostication after cardiac arrest: Insights from a prospective multicenter cohort. Resuscitation 2024; 202:110362. [PMID: 39151721 DOI: 10.1016/j.resuscitation.2024.110362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 08/09/2024] [Accepted: 08/11/2024] [Indexed: 08/19/2024]
Abstract
AIM To investigate the performance of the 2021 ERC/ESICM-recommended algorithm for predicting poor outcome after cardiac arrest (CA) and potential tools for predicting neurological recovery in patients with indeterminate outcome. METHODS Prospective, multicenter study on out-of-hospital CA survivors from 28 ICUs of the AfterROSC network. In patients comatose with a Glasgow Coma Scale motor score ≤3 at ≥72 h after resuscitation, we measured: (1) the accuracy of neurological examination, biomarkers (neuron-specific enolase, NSE), electrophysiology (EEG and SSEP) and neuroimaging (brain CT and MRI) for predicting poor outcome (modified Rankin scale score ≥4 at 90 days), and (2) the ability of low or decreasing NSE levels and benign EEG to predict good outcome in patients whose prognosis remained indeterminate. RESULTS Among 337 included patients, the ERC-ESICM algorithm predicted poor neurological outcome in 175 patients, and the positive predictive value for an unfavourable outcome was 100% [98-100]%. The specificity of individual predictors ranged from 90% for EEG to 100% for clinical examination and SSEP. Among the remaining 162 patients with indeterminate outcome, a combination of 2 favourable signs predicted good outcome with 99[96-100]% specificity and 23[11-38]% sensitivity. CONCLUSION All comatose resuscitated patients who fulfilled the ERC-ESICM criteria for poor outcome after CA had poor outcome at three months, even if a self-fulfilling prophecy cannot be completely excluded. In patients with indeterminate outcome (half of the population), favourable signs predicted neurological recovery, reducing prognostic uncertainty.
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Affiliation(s)
- Wulfran Bougouin
- AfterROSC Network Group, Paris, France; Université de Paris Cité, Inserm, Paris Cardiovascular Research Center, Paris, France; Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France.
| | - Jean-Baptiste Lascarrou
- AfterROSC Network Group, Paris, France; Université de Paris Cité, Inserm, Paris Cardiovascular Research Center, Paris, France; Service de Médecine Intensive Réanimation, University Hospital Center, Nantes, France
| | - Jonathan Chelly
- AfterROSC Network Group, Paris, France; Réanimation Polyvalente, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Toulon, France
| | - Sarah Benghanem
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, APHP, CHU Cochin, Université Paris Cité, Paris, France
| | - Guillaume Geri
- AfterROSC Network Group, Paris, France; Réanimation Polyvalente, Groupe Hospitalier Privé Ambroise Paré Hartmann, Neuilly-sur-Seine, France
| | - Julien Maizel
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CHU Amiens, Amiens, France
| | - Nicolas Fage
- AfterROSC Network Group, Paris, France; Département de médecine intensive réanimation et médecine hyperbare, CHU Angers, Angers, France
| | - Ghada Sboui
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CH Béthune, Béthune, France
| | - Nicolas Pichon
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CH Brive‑La‑Gaillarde, Brive, France
| | - Cédric Daubin
- AfterROSC Network Group, Paris, France; CHU de Caen Normandie, Médecine Intensive Réanimation, 14000 CAEN, France
| | - Bertrand Sauneuf
- AfterROSC Network Group, Paris, France; Réanimation Médecine Intensive, Centre Hospitalier Public du Cotentin, 50100 Cherbourg-en-Cotentin, France
| | - Nicolas Mongardon
- AfterROSC Network Group, Paris, France; Service d'Anesthésie‑Réanimation et Médecine Péri-Opératoire, APHP, CHU Henri Mondor, Créteil, France
| | - Fabio Taccone
- AfterROSC Network Group, Paris, France; Réanimation, ERASME, Brussels, Belgium
| | - Bertrand Hermann
- AfterROSC Network Group, Paris, France; Médecine Intensive-Réanimation, AP-HP, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris, France
| | - Gwenhaël Colin
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CHD Vendée, La Roche‑Sur‑Yon, France
| | - Olivier Lesieur
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CH La Rochelle, La Rochelle, France
| | - Nicolas Deye
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, APHP, CHU Lariboisière, Paris, France
| | - Nicolas Chudeau
- AfterROSC Network Group, Paris, France; Réanimation médico-chirurgicale, CH Le Mans, Le Mans, France
| | - Martin Cour
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, Hospices Civils Lyon, Lyon, France
| | - Jeremy Bourenne
- AfterROSC Network Group, Paris, France; Réanimation des Urgences et Déchocage, CHU La Timone, APHM, Marseille, France
| | - Kada Klouche
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CHU Montpellier, Montpellier, France
| | - Thomas Klein
- AfterROSC Network Group, Paris, France; Service de Médecine Intensive Réanimation Brabois, CHRU, Nancy, France
| | - Jean-Herlé Raphalen
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, APHP, CHU Necker, Paris, France
| | - Grégoire Muller
- AfterROSC Network Group, Paris, France; Centre Hospitalier Universitaire (CHU) d'Orléans, Médecine Intensive Réanimation, Université de Tours, MR INSERM 1327 ISCHEMIA, F37000 Tours, France; Clinical Research in Intensive Care and Sepsis-Trial Group for Global Evaluation and Research in Sepsis (CRICS_TRIGGERSep) French Clinical Research Infrastructure Network (F-CRIN) Research Network, France
| | - Arnaud Galbois
- AfterROSC Network Group, Paris, France; Service de Réanimation Polyvalente, Ramsay-Santé, Hôpital Privé Claude Galien, Quincy‑Sous‑Sénart, France
| | - Cédric Bruel
- AfterROSC Network Group, Paris, France; Service de Réanimation Polyvalente, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Sophie Jacquier
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CHU Tours, Tours, France
| | - Marine Paul
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CH Versailles, Le Chesnay, France
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alain Cariou
- AfterROSC Network Group, Paris, France; Université de Paris Cité, Inserm, Paris Cardiovascular Research Center, Paris, France; Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France
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van Putten MJAM, Ruijter BJ, Horn J, van Rootselaar AF, Tromp SC, van Kranen-Mastenbroek V, Gaspard N, Hofmeijer J. Quantitative Characterization of Rhythmic and Periodic EEG Patterns in Patients in a Coma After Cardiac Arrest and Association With Outcome. Neurology 2024; 103:e209608. [PMID: 38991197 DOI: 10.1212/wnl.0000000000209608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVES Rhythmic and periodic patterns (RPPs) on EEG in patients in a coma after cardiac arrest are associated with a poor neurologic outcome. We characterize RPPs using qEEG in relation to outcomes. METHODS Post hoc analysis was conducted on 172 patients in a coma after cardiac arrest from the TELSTAR trial, all with RPPs. Quantitative EEG included corrected background continuity index (BCI*), relative discharge power (RDP), discharge frequency, and shape similarity. Neurologic outcomes at 3 months after arrest were categorized as poor (CPC = 3-5) or good (CPC = 1-2). RESULTS A total of 16 patients (9.3%) had a good outcome. Patients with good outcomes showed later RPP onset (28.5 vs 20.1 hours after arrest, p < 0.05) and higher background continuity at RPP onset (BCI* = 0.83 vs BCI* = 0.59, p < 0.05). BCI* <0.45 at RPP onset, maximum BCI* <0.76, RDP >0.47, or shape similarity >0.75 were consistently associated with poor outcomes, identifying 36%, 22%, 40%, or 24% of patients with poor outcomes, respectively. In patients meeting both BCI* >0.44 at RPP onset and BCI* >0.75 within 72 hours, the probability of good outcomes doubled to 18%. DISCUSSION Sufficient EEG background continuity before and during RPPs is crucial for meaningful recovery. Background continuity, discharge power, and shape similarity can help select patients with relevant chances of recovery and may guide treatment. TRIAL REGISTRATION INFORMATION February 4, 2014, ClinicalTrial.gov, NCT02056236.
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Affiliation(s)
- Michel J A M van Putten
- From the Clinical Neurophysiology Group and Department of Clinical Neurophysiology (M.J.A.M.v.P.), University of Twente and Medisch Spectrum Twente; Department of Neurology (B.J.R.), OLVG, Amsterdam; Department of Intensive Care (Janneke Horn); Department of Neurology and Clinical Neurophysiology (A.-F.v.R.), Amsterdam Neuroscience, Amsterdam UMC, the Netherlands; Department of Clinical Neurophysiology (S.C.T.), St Antonius Hospital, Nieuwegein and Department of Neurology, LUMC, Leiden; Department of Neurology (V.v.K.-M.), Maastricht UMC+, the Netherlands; Department of Neurology (N.G.), Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium and Department of Neurology, Yale University School of Medicine, New Haven, CT; and Department of Neurology (Jeannette Hofmeijer), Rijnstate Hospital and Clinical Neurophysiology Group, University of Twente, the Netherlands
| | - Barry J Ruijter
- From the Clinical Neurophysiology Group and Department of Clinical Neurophysiology (M.J.A.M.v.P.), University of Twente and Medisch Spectrum Twente; Department of Neurology (B.J.R.), OLVG, Amsterdam; Department of Intensive Care (Janneke Horn); Department of Neurology and Clinical Neurophysiology (A.-F.v.R.), Amsterdam Neuroscience, Amsterdam UMC, the Netherlands; Department of Clinical Neurophysiology (S.C.T.), St Antonius Hospital, Nieuwegein and Department of Neurology, LUMC, Leiden; Department of Neurology (V.v.K.-M.), Maastricht UMC+, the Netherlands; Department of Neurology (N.G.), Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium and Department of Neurology, Yale University School of Medicine, New Haven, CT; and Department of Neurology (Jeannette Hofmeijer), Rijnstate Hospital and Clinical Neurophysiology Group, University of Twente, the Netherlands
| | - Janneke Horn
- From the Clinical Neurophysiology Group and Department of Clinical Neurophysiology (M.J.A.M.v.P.), University of Twente and Medisch Spectrum Twente; Department of Neurology (B.J.R.), OLVG, Amsterdam; Department of Intensive Care (Janneke Horn); Department of Neurology and Clinical Neurophysiology (A.-F.v.R.), Amsterdam Neuroscience, Amsterdam UMC, the Netherlands; Department of Clinical Neurophysiology (S.C.T.), St Antonius Hospital, Nieuwegein and Department of Neurology, LUMC, Leiden; Department of Neurology (V.v.K.-M.), Maastricht UMC+, the Netherlands; Department of Neurology (N.G.), Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium and Department of Neurology, Yale University School of Medicine, New Haven, CT; and Department of Neurology (Jeannette Hofmeijer), Rijnstate Hospital and Clinical Neurophysiology Group, University of Twente, the Netherlands
| | - Anne-Fleur van Rootselaar
- From the Clinical Neurophysiology Group and Department of Clinical Neurophysiology (M.J.A.M.v.P.), University of Twente and Medisch Spectrum Twente; Department of Neurology (B.J.R.), OLVG, Amsterdam; Department of Intensive Care (Janneke Horn); Department of Neurology and Clinical Neurophysiology (A.-F.v.R.), Amsterdam Neuroscience, Amsterdam UMC, the Netherlands; Department of Clinical Neurophysiology (S.C.T.), St Antonius Hospital, Nieuwegein and Department of Neurology, LUMC, Leiden; Department of Neurology (V.v.K.-M.), Maastricht UMC+, the Netherlands; Department of Neurology (N.G.), Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium and Department of Neurology, Yale University School of Medicine, New Haven, CT; and Department of Neurology (Jeannette Hofmeijer), Rijnstate Hospital and Clinical Neurophysiology Group, University of Twente, the Netherlands
| | - Selma C Tromp
- From the Clinical Neurophysiology Group and Department of Clinical Neurophysiology (M.J.A.M.v.P.), University of Twente and Medisch Spectrum Twente; Department of Neurology (B.J.R.), OLVG, Amsterdam; Department of Intensive Care (Janneke Horn); Department of Neurology and Clinical Neurophysiology (A.-F.v.R.), Amsterdam Neuroscience, Amsterdam UMC, the Netherlands; Department of Clinical Neurophysiology (S.C.T.), St Antonius Hospital, Nieuwegein and Department of Neurology, LUMC, Leiden; Department of Neurology (V.v.K.-M.), Maastricht UMC+, the Netherlands; Department of Neurology (N.G.), Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium and Department of Neurology, Yale University School of Medicine, New Haven, CT; and Department of Neurology (Jeannette Hofmeijer), Rijnstate Hospital and Clinical Neurophysiology Group, University of Twente, the Netherlands
| | - Vivianne van Kranen-Mastenbroek
- From the Clinical Neurophysiology Group and Department of Clinical Neurophysiology (M.J.A.M.v.P.), University of Twente and Medisch Spectrum Twente; Department of Neurology (B.J.R.), OLVG, Amsterdam; Department of Intensive Care (Janneke Horn); Department of Neurology and Clinical Neurophysiology (A.-F.v.R.), Amsterdam Neuroscience, Amsterdam UMC, the Netherlands; Department of Clinical Neurophysiology (S.C.T.), St Antonius Hospital, Nieuwegein and Department of Neurology, LUMC, Leiden; Department of Neurology (V.v.K.-M.), Maastricht UMC+, the Netherlands; Department of Neurology (N.G.), Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium and Department of Neurology, Yale University School of Medicine, New Haven, CT; and Department of Neurology (Jeannette Hofmeijer), Rijnstate Hospital and Clinical Neurophysiology Group, University of Twente, the Netherlands
| | - Nicolas Gaspard
- From the Clinical Neurophysiology Group and Department of Clinical Neurophysiology (M.J.A.M.v.P.), University of Twente and Medisch Spectrum Twente; Department of Neurology (B.J.R.), OLVG, Amsterdam; Department of Intensive Care (Janneke Horn); Department of Neurology and Clinical Neurophysiology (A.-F.v.R.), Amsterdam Neuroscience, Amsterdam UMC, the Netherlands; Department of Clinical Neurophysiology (S.C.T.), St Antonius Hospital, Nieuwegein and Department of Neurology, LUMC, Leiden; Department of Neurology (V.v.K.-M.), Maastricht UMC+, the Netherlands; Department of Neurology (N.G.), Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium and Department of Neurology, Yale University School of Medicine, New Haven, CT; and Department of Neurology (Jeannette Hofmeijer), Rijnstate Hospital and Clinical Neurophysiology Group, University of Twente, the Netherlands
| | - Jeannette Hofmeijer
- From the Clinical Neurophysiology Group and Department of Clinical Neurophysiology (M.J.A.M.v.P.), University of Twente and Medisch Spectrum Twente; Department of Neurology (B.J.R.), OLVG, Amsterdam; Department of Intensive Care (Janneke Horn); Department of Neurology and Clinical Neurophysiology (A.-F.v.R.), Amsterdam Neuroscience, Amsterdam UMC, the Netherlands; Department of Clinical Neurophysiology (S.C.T.), St Antonius Hospital, Nieuwegein and Department of Neurology, LUMC, Leiden; Department of Neurology (V.v.K.-M.), Maastricht UMC+, the Netherlands; Department of Neurology (N.G.), Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium and Department of Neurology, Yale University School of Medicine, New Haven, CT; and Department of Neurology (Jeannette Hofmeijer), Rijnstate Hospital and Clinical Neurophysiology Group, University of Twente, the Netherlands
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Perkins GD, Neumar R, Hsu CH, Hirsch KG, Aneman A, Becker LB, Couper K, Callaway CW, Hoedemaekers CWE, Lim SL, Meurer W, Olasveengen T, Sekhon MS, Skrifvars M, Soar J, Tsai MS, Vengamma B, Nolan JP. Improving Outcomes After Post-Cardiac Arrest Brain Injury: A Scientific Statement From the International Liaison Committee on Resuscitation. Resuscitation 2024; 201:110196. [PMID: 38932555 DOI: 10.1016/j.resuscitation.2024.110196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
This scientific statement presents a conceptual framework for the pathophysiology of post-cardiac arrest brain injury, explores reasons for previous failure to translate preclinical data to clinical practice, and outlines potential paths forward. Post-cardiac arrest brain injury is characterized by 4 distinct but overlapping phases: ischemic depolarization, reperfusion repolarization, dysregulation, and recovery and repair. Previous research has been challenging because of the limitations of laboratory models; heterogeneity in the patient populations enrolled; overoptimistic estimation of treatment effects leading to suboptimal sample sizes; timing and route of intervention delivery; limited or absent evidence that the intervention has engaged the mechanistic target; and heterogeneity in postresuscitation care, prognostication, and withdrawal of life-sustaining treatments. Future trials must tailor their interventions to the subset of patients most likely to benefit and deliver this intervention at the appropriate time, through the appropriate route, and at the appropriate dose. The complexity of post-cardiac arrest brain injury suggests that monotherapies are unlikely to be as successful as multimodal neuroprotective therapies. Biomarkers should be developed to identify patients with the targeted mechanism of injury, to quantify its severity, and to measure the response to therapy. Studies need to be adequately powered to detect effect sizes that are realistic and meaningful to patients, their families, and clinicians. Study designs should be optimized to accelerate the evaluation of the most promising interventions. Multidisciplinary and international collaboration will be essential to realize the goal of developing effective therapies for post-cardiac arrest brain injury.
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Hoorn CSM, Admiraal MM, Koelman JHTM, Stam CJ, van Straaten ECW, Slot RER, Horn J, van Rootselaar AF. Clinical observation: Rhythmic and periodic EEG patterns in postanoxic coma can possibly be related to propofol discontinuation. Resuscitation 2024; 201:110255. [PMID: 38806141 DOI: 10.1016/j.resuscitation.2024.110255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVES To investigate whether rhythmic/periodic EEG patterns (RPP) appearing after propofol discontinuation are more likely to be related to the elimination phase of propofol, or are an expression of severe brain damage. METHODS In a retrospective cohort of comatose postanoxic patients, EEG was assessed one hour before (baseline) and on hour after discontinuation of propofol. Presence and duration of RPP were related to (changes in) EEG background pattern and duration of sedation. RESULTS In eleven (of 36 eligible) patients RPP appeared after propofol discontinuation and disappeared in seven of these patients within one hour. A continuous background pattern at baseline and shorter duration of propofol infusion seemed associated with (earlier) spontaneous disappearance of RPP. In ten patients with RPP at baseline, the EEG did not change, and in one patient it changed into burst-suppression. CONCLUSION Our findings suggest that RPP after propofol discontinuation could be propofol-related. DISCUSSION RPP might be related to propofol discontinuation rather than an expression of severe brain damage, especially in case of, and congruent with, a continuous pattern at the time of propofol discontinuation. This opens a new insight in this phenomenon and its transient nature. In clinical practice, we suggest to consider the timing of propofol discontinuation when assessing the EEG signal in postanoxic patients.
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Affiliation(s)
- Cathaleine S M Hoorn
- Amsterdam UMC, University of Amsterdam, Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, Netherlands
| | - Marjolein M Admiraal
- Amsterdam UMC, University of Amsterdam, Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, Netherlands
| | - Johannes H T M Koelman
- Amsterdam UMC, University of Amsterdam, Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, Netherlands
| | - Cornelis J Stam
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience, De Boelelaan 1117, Amsterdam, Netherlands
| | - Elisabeth C W van Straaten
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience, De Boelelaan 1117, Amsterdam, Netherlands
| | - Rosalinde E R Slot
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience, De Boelelaan 1117, Amsterdam, Netherlands
| | - Janneke Horn
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care Medicine, Meibergdreef 9, Amsterdam, Netherlands
| | - Anne-Fleur van Rootselaar
- Amsterdam UMC, University of Amsterdam, Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, Netherlands.
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Bitar R, Khan UM, Rosenthal ES. Utility and rationale for continuous EEG monitoring: a primer for the general intensivist. Crit Care 2024; 28:244. [PMID: 39014421 PMCID: PMC11251356 DOI: 10.1186/s13054-024-04986-0] [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: 02/06/2024] [Accepted: 06/09/2024] [Indexed: 07/18/2024] Open
Abstract
This review offers a comprehensive guide for general intensivists on the utility of continuous EEG (cEEG) monitoring for critically ill patients. Beyond the primary role of EEG in detecting seizures, this review explores its utility in neuroprognostication, monitoring neurological deterioration, assessing treatment responses, and aiding rehabilitation in patients with encephalopathy, coma, or other consciousness disorders. Most seizures and status epilepticus (SE) events in the intensive care unit (ICU) setting are nonconvulsive or subtle, making cEEG essential for identifying these otherwise silent events. Imaging and invasive approaches can add to the diagnosis of seizures for specific populations, given that scalp electrodes may fail to identify seizures that may be detected by depth electrodes or electroradiologic findings. When cEEG identifies SE, the risk of secondary neuronal injury related to the time-intensity "burden" often prompts treatment with anti-seizure medications. Similarly, treatment may be administered for seizure-spectrum activity, such as periodic discharges or lateralized rhythmic delta slowing on the ictal-interictal continuum (IIC), even when frank seizures are not evident on the scalp. In this setting, cEEG is utilized empirically to monitor treatment response. Separately, cEEG has other versatile uses for neurotelemetry, including identifying the level of sedation or consciousness. Specific conditions such as sepsis, traumatic brain injury, subarachnoid hemorrhage, and cardiac arrest may each be associated with a unique application of cEEG; for example, predicting impending events of delayed cerebral ischemia, a feared complication in the first two weeks after subarachnoid hemorrhage. After brief training, non-neurophysiologists can learn to interpret quantitative EEG trends that summarize elements of EEG activity, enhancing clinical responsiveness in collaboration with clinical neurophysiologists. Intensivists and other healthcare professionals also play crucial roles in facilitating timely cEEG setup, preventing electrode-related skin injuries, and maintaining patient mobility during monitoring.
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Affiliation(s)
- Ribal Bitar
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Usaamah M Khan
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA.
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Parikh H, Sun H, Amerineni R, Rosenthal ES, Volfovsky A, Rudin C, Westover MB, Zafar SF. How many patients do you need? Investigating trial designs for anti-seizure treatment in acute brain injury patients. Ann Clin Transl Neurol 2024; 11:1681-1690. [PMID: 38867375 PMCID: PMC11251465 DOI: 10.1002/acn3.52059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND/OBJECTIVES Epileptiform activity (EA), including seizures and periodic patterns, worsens outcomes in patients with acute brain injuries (e.g., aneurysmal subarachnoid hemorrhage [aSAH]). Randomized control trials (RCTs) assessing anti-seizure interventions are needed. Due to scant drug efficacy data and ethical reservations with placebo utilization, and complex physiology of acute brain injury, RCTs are lacking or hindered by design constraints. We used a pharmacological model-guided simulator to design and determine the feasibility of RCTs evaluating EA treatment. METHODS In a single-center cohort of adults (age >18) with aSAH and EA, we employed a mechanistic pharmacokinetic-pharmacodynamic framework to model treatment response using observational data. We subsequently simulated RCTs for levetiracetam and propofol, each with three treatment arms mirroring clinical practice and an additional placebo arm. Using our framework, we simulated EA trajectories across treatment arms. We predicted discharge modified Rankin Scale as a function of baseline covariates, EA burden, and drug doses using a double machine learning model learned from observational data. Differences in outcomes across arms were used to estimate the required sample size. RESULTS Sample sizes ranged from 500 for levetiracetam 7 mg/kg versus placebo, to >4000 for levetiracetam 15 versus 7 mg/kg to achieve 80% power (5% type I error). For propofol 1 mg/kg/h versus placebo, 1200 participants were needed. Simulations comparing propofol at varying doses did not reach 80% power even at samples >1200. CONCLUSIONS Our simulations using drug efficacy show sample sizes are infeasible, even for potentially unethical placebo-control trials. We highlight the strength of simulations with observational data to inform the null hypotheses and propose use of this simulation-based RCT paradigm to assess the feasibility of future trials of anti-seizure treatment in acute brain injury.
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Affiliation(s)
- Harsh Parikh
- Department of BiostatisticsJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Haoqi Sun
- Department of NeurologyBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Rajesh Amerineni
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Eric S. Rosenthal
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | | | - Cynthia Rudin
- Department of Computer ScienceDuke UniversityDukeNorth CarolinaUSA
| | - M. Brandon Westover
- Department of NeurologyBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Sahar F. Zafar
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
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Hou HX, Pang L, Zhao L, Xing J. Ferroptosis-related gene MAPK3 is associated with the neurological outcome after cardiac arrest. PLoS One 2024; 19:e0301647. [PMID: 38885209 PMCID: PMC11182507 DOI: 10.1371/journal.pone.0301647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 03/19/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Neuronal ferroptosis is closely related to the disease of the nervous system, and the objective of the present study was to recognize and verify the potential ferroptosis-related genes to forecast the neurological outcome after cardiac arrest. METHODS Cardiac Arrest-related microarray datasets GSE29540 and GSE92696 were downloaded from GEO and batch normalization of the expression data was performed using "sva" of the R package. GSE29540 was analyzed to identify DEGs. Venn diagram was applied to recognize ferroptosis-related DEGs from the DEGs. Subsequently, The Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis were performed, and PPI network was applied to screen hub genes. Receiver operating characteristic (ROC) curves were adopted to determine the predictive value of the biomarkers, and the GSE92696 dataset was applied to further evaluate the diagnostic efficacy of the biomarkers. We explore transcription factors and miRNAs associated with hub genes. The "CIBERSORT" package of R was utilized to analyse the proportion infiltrating immune cells. Finally, validated by a series of experiments at the cellular level. RESULTS 112 overlapping ferroptosis-related DEGs were further obtained via intersecting these DEGs and ferroptosis-related genes. The GO and KEGG analysis demonstrate that ferroptosis-related DEGs are mainly involved in response to oxidative stress, ferroptosis, apoptosis, IL-17 signalling pathway, autophagy, toll-like receptor signalling pathway. The top 10 hub genes were selected, including HIF1A, MAPK3, PPARA, IL1B, PTGS2, RELA, TLR4, KEAP1, SREBF1, SIRT6. Only MAPK3 was upregulated in both GSE29540 and GAE92696. The AUC values of the MAPK3 are 0.654 and 0.850 in GSE29540 and GSE92696 respectively. The result of miRNAs associated with hub genes indicates that hsa-miR-214-3p and hsa-miR-483-5p can regulate the expression of MAPK3. MAPK3 was positively correlated with naive B cells, macrophages M0, activated dendritic cells and negatively correlated with activated CD4 memory T cells, CD8 T cells, and memory B cells. Compared to the OGD4/R24 group, the OGD4/R12 group had higher MAPK3 expression at both mRNA and protein levels and more severe ferroptosis. CONCLUSION In summary, the MAPK3 ferroptosis-related gene could be used as a biomarker to predict the neurological outcome after cardiac arrest. Potential biological pathways provide novel insights into the pathogenesis of cardiac arrest.
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Affiliation(s)
- Hong xiang Hou
- Department of Emergency, The First Hospital of Jilin University, Changchun, China
| | - Li Pang
- Department of Emergency, The First Hospital of Jilin University, Changchun, China
| | - Liang Zhao
- Rehabilitation Department, The First Hospital of Jilin University, Changchun, China
| | - Jihong Xing
- Department of Emergency, The First Hospital of Jilin University, Changchun, China
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8
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Cutillo G, Bonacchi R, Vabanesi M, Cecchetti G, Bellini A, Filippi M, Fanelli GF. Perampanel as an Add-On Therapy in Patients with Refractory Status Epilepticus and Postanoxic Encephalopathy: A Real-Life Single-Center Retrospective Cohort Study. Neurocrit Care 2024:10.1007/s12028-024-02019-w. [PMID: 38872031 DOI: 10.1007/s12028-024-02019-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/16/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Data on the efficacy of perampanel in refractory status epilepticus (RSE) and postanoxic encephalopathy (PAE) are limited; its use in such conditions is currently off-label. METHODS We conducted a retrospective cohort study of consecutive adult patients with RSE, including PAE, exhibiting electroencephalographic patterns indicative of status epilepticus who were treated at our center (January 2018 to December 2022) with assessment of clinical and electroencephalographic outcomes. RESULTS Thirty-six patients were included in the study, of whom 29 had nonanoxic RSE and 7 had PAE. Within the nonanoxic RSE subgroup, 45% (13 of 29; 95% confidence interval [CI] 27-63%) of study participants were responders, 34% (10 of 29; 95% CI 17-52%) were partial responders, and 21% (6 of 29; 95% CI 6-35%) were nonresponders. In the PAE subgroup (n = 7), no patients fully responded to perampanel; 43% (3 of 7; 95% CI 6-80%) were partial responders, and 57% (4 of 7; 95% CI 20-95%) were nonresponders. Responder and nonresponder study participants exhibited overlapping baseline characteristics. No significant differences in duration of hospitalization were observed between responders and nonresponders in both subgroups. Responders in the RSE subgroup had a median discharge modified Rankin Scale score of 3 (interquartile range 3-4), and nonresponders had a median discharge modified Rankin Scale score of 5 (interquartile range 5-6). CONCLUSIONS Despite limitations from the retrospective design and the small population size, this study suggests that perampanel use in nonanoxic RSE appears to yield promising results at moderate doses, including a tendency toward a better functional outcome at discharge, without significant adverse effects. However, in patients with PAE, the drug seems to show suboptimal performance. Perampanel appears to have promising efficacy as an add-on therapy in nonanoxic RSE. However, in patients with PAE, its efficacy seems to be lower. Further studies are warranted to confirm these observations.
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Affiliation(s)
- Gianni Cutillo
- Neurophysiology Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Raffaello Bonacchi
- Vita-Salute San Raffaele University, Milan, Italy
- Neuroradiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
| | - Marco Vabanesi
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
| | - Giordano Cecchetti
- Neurophysiology Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
| | - Anna Bellini
- Neurophysiology Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
| | - Massimo Filippi
- Neurophysiology Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy.
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
- Neurorehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy.
- Neuroimaging Research Unit, Division of Neuroscience, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy.
| | - Giovanna F Fanelli
- Neurophysiology Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
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9
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Steinberg A. Emergent Management of Hypoxic-Ischemic Brain Injury. Continuum (Minneap Minn) 2024; 30:588-610. [PMID: 38830064 DOI: 10.1212/con.0000000000001426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article outlines interventions used to improve outcomes for patients with hypoxic-ischemic brain injury after cardiac arrest. LATEST DEVELOPMENTS Emergent management of patients after cardiac arrest requires prevention and treatment of primary and secondary brain injury. Primary brain injury is minimized by excellent initial resuscitative efforts. Secondary brain injury prevention requires the detection and correction of many pathophysiologic processes that may develop in the hours to days after the initial arrest. Key physiologic parameters important to secondary brain injury prevention include optimization of mean arterial pressure, cerebral perfusion, oxygenation and ventilation, intracranial pressure, temperature, and cortical hyperexcitability. This article outlines recent data regarding the treatment and prevention of secondary brain injury. Different patients likely benefit from different treatment strategies, so an individualized approach to treatment and prevention of secondary brain injury is advisable. Clinicians must use multimodal sources of data to prognosticate outcomes after cardiac arrest while recognizing that all prognostic tools have shortcomings. ESSENTIAL POINTS Neurologists should be involved in the postarrest care of patients with hypoxic-ischemic brain injury to improve their outcomes. Postarrest care requires nuanced and patient-centered approaches to the prevention and treatment of primary and secondary brain injury and neuroprognostication.
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Fong MWK, Stephens E, Brockington A, Jayabal J, Scott S, Zhang T, Litchfield R, Beilharz E, Dalziel SR, Jones P, Yates K, Thornton V, Bergin PS. Status epilepticus in Auckland, New Zealand: Treatment patterns and determinants of outcome in a prospective population-based cohort. Epilepsia 2024; 65:1605-1619. [PMID: 38634858 DOI: 10.1111/epi.17975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/01/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Determination of the real-world performance of a health care system in the treatment of status epilepticus (SE). METHODS Prospective, multicenter population-based study of SE in Auckland, New Zealand (NZ) over 1 year, with data recorded in the EpiNet database. Focus on treatment patterns and determinants of SE duration and 30-day mortality. The incidence, etiology, ethnic discrepancies, and seizure characteristics of this cohort have been published previously. RESULTS A total of 365 patients were included in this treatment cohort; 326 patients (89.3%) were brought to hospital because of SE, whereas 39 patients (10.7%) developed SE during a hospital admission for another reason. Overall, 190 (52.1%) had a known history of epilepsy and 254 (70.0%) presented with SE with prominent motor activity. The mean Status Epilepticus Severity Score (STESS) was 2.15 and the mean SE duration of all patients was 44 min. SE self-terminated without any treatment in 84 patients (22.7%). Earlier administration of appropriately dosed benzodiazepine in the pre-hospital setting was a major determinant of SE duration. Univariate analysis demonstrated that mortality was significantly higher in older patients, patients with longer durations of SE, higher STESS, and patients who developed SE in hospital, but these did not maintain significance with multivariate analysis. There was no difference in the performance of the health care system in the treatment of SE across ethnic groups. SIGNIFICANCE When SE was defined as 10 continuous minutes of seizure, overall mortality was lower than expected and many patients had self-limited presentations for which no treatment was required. Although there were disparities in the incidence of SE across ethnic groups there was no difference in treatment or outcome. The finding highlights the benefit of a health care system designed to deliver universal health care.
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Affiliation(s)
- Michael W K Fong
- Westmead Comprehensive Epilepsy Centre, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Eleanor Stephens
- Westmead Comprehensive Epilepsy Centre, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Alice Brockington
- Auckland District Health Board, Grafton, Auckland, New Zealand
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Jayaganth Jayabal
- Auckland District Health Board, Grafton, Auckland, New Zealand
- Pantai-Gleneagles Hospital, Penang and Sungai Petani, Malaysia
| | - Shona Scott
- Auckland District Health Board, Grafton, Auckland, New Zealand
- Western General Hospital, Edinburgh, UK
| | - Tony Zhang
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | | | - Erica Beilharz
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | - Stuart R Dalziel
- Auckland District Health Board, Grafton, Auckland, New Zealand
- Department of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Peter Jones
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | - Kim Yates
- Waitematā District Health Board, Auckland, New Zealand
| | | | - Peter S Bergin
- Auckland District Health Board, Grafton, Auckland, New Zealand
- Centre for Brain Research, University of Auckland, Auckland, New Zealand
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11
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Annoni F, Gouvea Bogossian E, Peluso L, Su F, Moreau A, Nobile L, Casu SG, Sterchele ED, Calabro L, Salvagno M, Oddo M, Taccone FS. Ketone Bodies after Cardiac Arrest: A Narrative Review and the Rationale for Use. Cells 2024; 13:784. [PMID: 38727320 PMCID: PMC11083685 DOI: 10.3390/cells13090784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/27/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
Cardiac arrest survivors suffer the repercussions of anoxic brain injury, a critical factor influencing long-term prognosis. This injury is characterised by profound and enduring metabolic impairment. Ketone bodies, an alternative energetic resource in physiological states such as exercise, fasting, and extended starvation, are avidly taken up and used by the brain. Both the ketogenic diet and exogenous ketone supplementation have been associated with neuroprotective effects across a spectrum of conditions. These include refractory epilepsy, neurodegenerative disorders, cognitive impairment, focal cerebral ischemia, and traumatic brain injuries. Beyond this, ketone bodies possess a plethora of attributes that appear to be particularly favourable after cardiac arrest. These encompass anti-inflammatory effects, the attenuation of oxidative stress, the improvement of mitochondrial function, a glucose-sparing effect, and the enhancement of cardiac function. The aim of this manuscript is to appraise pertinent scientific literature on the topic through a narrative review. We aim to encapsulate the existing evidence and underscore the potential therapeutic value of ketone bodies in the context of cardiac arrest to provide a rationale for their use in forthcoming translational research efforts.
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Affiliation(s)
- Filippo Annoni
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Humanitas Gavazzeni Hospital, 24125 Bergamo, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | - Fuhong Su
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Anthony Moreau
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Leda Nobile
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Stefano Giuseppe Casu
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Elda Diletta Sterchele
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Lorenzo Calabro
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Michele Salvagno
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Mauro Oddo
- Medical Directorate for Research, Education and Innovation, Direction Médicale, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, 1011 Lausanne, Switzerland
| | - Fabio Silvio Taccone
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
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12
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Bencsik CM, Kramer AH, Couillard P, MacKay M, Kromm JA. Postarrest Neuroprognostication: Practices and Opinions of Canadian Physicians. Can J Neurol Sci 2024; 51:404-415. [PMID: 37489539 DOI: 10.1017/cjn.2023.261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND Objective, evidence-based neuroprognostication of postarrest patients is crucial to avoid inappropriate withdrawal of life-sustaining therapies or prolonged, invasive, and costly therapies that could perpetuate suffering when there is no chance of an acceptable recovery. Postarrest prognostication guidelines exist; however, guideline adherence and practice variability are unknown. OBJECTIVE To investigate Canadian practices and opinions regarding assessment of neurological prognosis in postarrest patients. METHODS An anonymous electronic survey was distributed to physicians who care for adult postarrest patients. RESULTS Of the 134 physicians who responded to the survey, 63% had no institutional protocols for neuroprognostication. While the use of targeted temperature management did not affect the timing of neuroprognostication, an increasing number of clinical findings suggestive of a poor prognosis affected the timing of when physicians were comfortable concluding patients had a poor prognosis. Variability existed in what factors clinicians' thought were confounders. Physicians identified bilaterally absent pupillary light reflexes (85%), bilaterally absent corneal reflexes (80%), and status myoclonus (75%) as useful in determining poor prognosis. Computed tomography, magnetic resonance imaging, and spot electroencephalography were the most useful and accessible tests. Somatosensory evoked potentials were useful, but logistically challenging. Serum biomarkers were unavailable at most centers. Most (79%) physicians agreed ≥2 definitive findings on neurologic exam, electrophysiologic tests, neuroimaging, and/or biomarkers are required to determine a poor prognosis with a high degree of certainty. Distress during the process of neuroprognostication was reported by 70% of physicians and 51% request a second opinion from an external expert. CONCLUSION Significant variability exists in post-cardiac arrest neuroprognostication practices among Canadian physicians.
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Affiliation(s)
- Caralyn M Bencsik
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Andreas H Kramer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Philippe Couillard
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | | | - Julie A Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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13
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Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [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: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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14
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Bencsik C, Josephson C, Soo A, Ainsworth C, Savard M, van Diepen S, Kramer A, Kromm J. The Evolving Role of Electroencephalography in Postarrest Care. Can J Neurol Sci 2024:1-13. [PMID: 38572611 DOI: 10.1017/cjn.2024.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Electroencephalography is an accessible, portable, noninvasive and safe means of evaluating a patient's brain activity. It can aid in diagnosis and management decisions for post-cardiac arrest patients with seizures, myoclonus and other non-epileptic movements. It also plays an important role in a multimodal approach to neuroprognostication predicting both poor and favorable outcomes. Individuals ordering, performing and interpreting these tests, regardless of the indication, should understand the supporting evidence, logistical considerations, limitations and impact the results may have on postarrest patients and their families as outlined herein.
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Affiliation(s)
- Caralyn Bencsik
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Colin Josephson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Martin Savard
- Département de Médecine, Université Laval, Quebec City, QC, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Julie Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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15
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Peluso L, Stropeni S, Macchini E, Peratoner C, Ferlini L, Legros B, Minini A, Bogossian EG, Garone A, Creteur J, Taccone FS, Gaspard N. Delayed Deterioration of Electroencephalogram in Patients with Cardiac Arrest: A Cohort Study. Neurocrit Care 2024; 40:633-644. [PMID: 37498454 DOI: 10.1007/s12028-023-01791-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 06/23/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND The aim of this study was to assess the prevalence of delayed deterioration of electroencephalogram (EEG) in patients with cardiac arrest (CA) without early highly malignant patterns and to determine their associations with clinical findings. METHODS This was a retrospective study of adult patients with CA admitted to the intensive care unit (ICU) of a university hospital. We included all patients with CA who had a normal voltage EEG, no more than 10% discontinuity, and absence of sporadic epileptic discharges, periodic discharges, or electrographic seizures. Delayed deterioration was classified as the following: (1) epileptic deterioration, defined as the appearance, at least 24 h after CA, of sporadic epileptic discharges, periodic discharges, and status epilepticus; or (2) background deterioration, defined as increasing discontinuity or progressive attenuation of the background at least 24 h after CA. The end points were the incidence of EEG deteriorations and their association with clinical features and ICU mortality. RESULTS We enrolled 188 patients in the analysis. The ICU mortality was 46%. Overall, 30 (16%) patients presented with epileptic deterioration and 9 (5%) patients presented with background deterioration; of those, two patients presented both deteriorations. Patients with epileptic deterioration more frequently had an out-of-hospital CA, and higher time to return of spontaneous circulation and less frequently had bystander resuscitation than others. Patients with background deterioration showed a predominantly noncardiac cause, more frequently developed shock, and had multiple organ failure compared with others. Patients with epileptic deterioration presented with a higher ICU mortality (77% vs. 41%; p < 0.01) than others, whereas all patients with background deterioration died in the ICU. CONCLUSIONS Delayed EEG deterioration was associated with high mortality rate. Epileptic deterioration was associated with worse characteristics of CA, whereas background deterioration was associated with shock and multiple organ failure.
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Affiliation(s)
- Lorenzo Peluso
- Departement of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20072, Pieve Emanuele, Italy.
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium.
- Departement of Anesthesiology and Intensive Care, Humanitas Gavazzeni, Via Mauro Gavazzeni, 21, 24125, Bergamo, Italy.
| | - Serena Stropeni
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisabetta Macchini
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Caterina Peratoner
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Ferlini
- Department of Neurology, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Benjamin Legros
- Department of Neurology, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Garone
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
- Department of Neurology, Yale University Medical School, 15, York Street, New Haven, CT, 06510, USA
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16
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van Diepen S, Le May MR, Alfaro P, Goldfarb MJ, Luk A, Mathew R, Peretz-Larochelle M, Rayner-Hartley E, Russo JJ, Senaratne JM, Ainsworth C, Belley-Côté E, Fordyce CB, Kromm J, Overgaard CB, Schnell G, Wong GC. Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Clinical Practice Update on Optimal Post Cardiac Arrest and Refractory Cardiac Arrest Patient Care. Can J Cardiol 2024; 40:524-539. [PMID: 38604702 DOI: 10.1016/j.cjca.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 04/13/2024] Open
Abstract
Survival to hospital discharge among patients with out-of-hospital cardiac arrest (OHCA) is low and important regional differences in treatment practices and survival have been described. Since the 2017 publication of the Canadian Cardiovascular Society's position statement on OHCA care, multiple randomized controlled trials have helped to better define optimal post cardiac arrest care. This working group provides updated guidance on the timing of cardiac catheterization in patients with ST-elevation and without ST-segment elevation, on a revised temperature control strategy targeting normothermia instead of hypothermia, blood pressure, oxygenation, and ventilation parameters, and on the treatment of rhythmic and periodic electroencephalography patterns in patients with a resuscitated OHCA. In addition, prehospital trials have helped craft new expert opinions on antiarrhythmic strategies (amiodarone or lidocaine) and outline the potential role for double sequential defibrillation in patients with refractory cardiac arrest when equipment and training is available. Finally, we advocate for regionalized OHCA care systems with admissions to a hospital capable of integrating their post OHCA care with comprehensive on-site cardiovascular services and provide guidance on the potential role of extracorporeal cardiopulmonary resuscitation in patients with refractory cardiac arrest. We believe that knowledge translation through national harmonization and adoption of contemporary best practices has the potential to improve survival and functional outcomes in the OHCA population.
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Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Michel R Le May
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Patricia Alfaro
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
| | - Michael J Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Adriana Luk
- Division of Cardiology, Department of Medicine, University of Toronto and the Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Mathew
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Maude Peretz-Larochelle
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Erin Rayner-Hartley
- Royal Columbian Hospital, Division of Cardiology, University of British Columbia, New Westminster, British Columbia, Canada
| | - Juan J Russo
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Janek M Senaratne
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Emilie Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Kromm
- Department of Critical Care, Department of Clinical Neurosciences, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christopher B Overgaard
- Division of Cardiology, Department of Medicine, University of Toronto and the Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Gregory Schnell
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, Vancouver General Hospital and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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17
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Xie D, Toutant D, Ng MC. Residual Seizure Rate of Intermittent Inpatient EEG Compared to a Continuous EEG Model. Can J Neurol Sci 2024; 51:246-254. [PMID: 37282558 DOI: 10.1017/cjn.2023.241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Subclinical seizures are common in hospitalized patients and require electroencephalography (EEG) for detection and intervention. At our institution, continuous EEG (cEEG) is not available, but intermittent EEGs are subject to constant live interpretation. As part of quality improvement (QI), we sought to estimate the residual missed seizure rate at a typical quaternary Canadian health care center without cEEG. METHODS We calculated residual risk percentages using the clinically validated 2HELPS2B score to risk-stratify EEGs before deriving a risk percentage using a MATLAB calculator which modeled the risk decay curve for each recording. We generated a range of estimated residual seizure rates depending on whether a pre-cEEG screening EEG was simulated, EEGs showing seizures were included, or repeat EEGs on the same patient were excluded. RESULTS Over a 4-month QI period, 499 inpatient EEGs were scored as low (n = 125), medium (n = 123), and high (n = 251) seizure risk according to 2HELPS2B criteria. Median recording duration was 1:00:06 (interquartile range, IQR 30:40-2:21:10). The model with highest residual seizure rate included recordings with confirmed electrographic seizures (median 20.83%, IQR 20.6-26.6%), while the model with lowest residual seizure rate was in seizure-free recordings (median 10.59%, IQR 4%-20.6%). These rates were significantly higher than the benchmark 5% miss-rate threshold set by 2HELPS2B (p<0.0001). CONCLUSIONS We estimate that intermittent inpatient EEG misses 2-4 times more subclinical seizures than the 2HELPS2B-determined acceptable 5% seizure miss-rate threshold for cEEG. Future research is needed to determine the impact of potentially missed seizures on clinical care.
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Affiliation(s)
- Dave Xie
- Undergraduate Medical Education, University of Manitoba, Winnipeg, MB, Canada
| | - Darion Toutant
- Biomedical Engineering Program, University of Manitoba, Winnipeg, MB, Canada
| | - Marcus C Ng
- Biomedical Engineering Program, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurology, University of Manitoba, Winnipeg, MB, Canada
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18
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Lapalme-Remis S. Beyond Seizures: The Usefulness of EEG in Septic Patients. Epilepsy Curr 2024; 24:84-86. [PMID: 39280044 PMCID: PMC11394404 DOI: 10.1177/15357597231217652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2024] Open
Abstract
[Box: see text]
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19
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [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: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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20
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Gonzalez D, Dahiya G, Mutirangura P, Ergando T, Mello G, Singh R, Bentho O, Elliott AM. Post Cardiac Arrest Care in the Cardiac Intensive Care Unit. Curr Cardiol Rep 2024; 26:35-49. [PMID: 38214836 DOI: 10.1007/s11886-023-02015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE OF REVIEW Cardiac arrests constitute a leading cause of mortality in the adult population and cardiologists are often tasked with the management of patients following cardiac arrest either as a consultant or primary provider in the cardiac intensive care unit. Familiarity with evidence-based practice for post-cardiac arrest care is a requisite for optimizing outcomes in this highly morbid group. This review will highlight important concepts necessary to managing these patients. RECENT FINDINGS Emerging evidence has further elucidated optimal care of post-arrest patients including timing for routine coronary angiography, utility of therapeutic hypothermia, permissive hypercapnia, and empiric aspiration pneumonia treatment. The complicated state of multi-organ failure following cardiac arrest needs to be carefully optimized by the clinician to prevent further neurologic injury and promote systemic recovery. Future studies should be aimed at understanding if these findings extend to specific patient populations, especially those at the highest risk for poor outcomes.
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Affiliation(s)
- Daniel Gonzalez
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Garima Dahiya
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, USA
| | | | | | - Gregory Mello
- University of Minnesota Medical School, Minneapolis, USA
| | - Rahul Singh
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Oladi Bentho
- Department of Neurology, University of Minnesota, Minneapolis, USA
| | - Andrea M Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA.
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21
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Slovis JC, Bach A, Beaulieu F, Zuckerberg G, Topjian A, Kirschen MP. Neuromonitoring after Pediatric Cardiac Arrest: Cerebral Physiology and Injury Stratification. Neurocrit Care 2024; 40:99-115. [PMID: 37002474 PMCID: PMC10544744 DOI: 10.1007/s12028-023-01685-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 01/30/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Significant long-term neurologic disability occurs in survivors of pediatric cardiac arrest, primarily due to hypoxic-ischemic brain injury. Postresuscitation care focuses on preventing secondary injury and the pathophysiologic cascade that leads to neuronal cell death. These injury processes include reperfusion injury, perturbations in cerebral blood flow, disturbed oxygen metabolism, impaired autoregulation, cerebral edema, and hyperthermia. Postresuscitation care also focuses on early injury stratification to allow clinicians to identify patients who could benefit from neuroprotective interventions in clinical trials and enable targeted therapeutics. METHODS In this review, we provide an overview of postcardiac arrest pathophysiology, explore the role of neuromonitoring in understanding postcardiac arrest cerebral physiology, and summarize the evidence supporting the use of neuromonitoring devices to guide pediatric postcardiac arrest care. We provide an in-depth review of the neuromonitoring modalities that measure cerebral perfusion, oxygenation, and function, as well as neuroimaging, serum biomarkers, and the implications of targeted temperature management. RESULTS For each modality, we provide an in-depth review of its impact on treatment, its ability to stratify hypoxic-ischemic brain injury severity, and its role in neuroprognostication. CONCLUSION Potential therapeutic targets and future directions are discussed, with the hope that multimodality monitoring can shift postarrest care from a one-size-fits-all model to an individualized model that uses cerebrovascular physiology to reduce secondary brain injury, increase accuracy of neuroprognostication, and improve outcomes.
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Affiliation(s)
- Julia C Slovis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA.
| | - Ashley Bach
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Forrest Beaulieu
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Gabe Zuckerberg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
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22
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Perman SM, Elmer J, Maciel CB, Uzendu A, May T, Mumma BE, Bartos JA, Rodriguez AJ, Kurz MC, Panchal AR, Rittenberger JC. 2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2024; 149:e254-e273. [PMID: 38108133 DOI: 10.1161/cir.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.
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23
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Tinti L, Lawson T, Molteni E, Kondziella D, Rass V, Sharshar T, Bodien YG, Giacino JT, Mayer SA, Amiri M, Muehlschlegel S, Venkatasubba Rao CP, Vespa PM, Menon DK, Citerio G, Helbok R, McNett M. Research considerations for prospective studies of patients with coma and disorders of consciousness. Brain Commun 2024; 6:fcae022. [PMID: 38344653 PMCID: PMC10853976 DOI: 10.1093/braincomms/fcae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/04/2024] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
Disorders of consciousness are neurological conditions characterized by impaired arousal and awareness of self and environment. Behavioural responses are absent or are present but fluctuate. Disorders of consciousness are commonly encountered as a consequence of both acute and chronic brain injuries, yet reliable epidemiological estimates would require inclusive, operational definitions of the concept, as well as wider knowledge dissemination among involved professionals. Whereas several manifestations have been described, including coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state, a comprehensive neurobiological definition for disorders of consciousness is still lacking. The scientific literature is primarily observational, and studies-specific aetiologies lead to disorders of consciousness. Despite advances in these disease-related forms, there remains uncertainty about whether disorders of consciousness are a disease-agnostic unitary entity with a common mechanism, prognosis or treatment response paradigm. Our knowledge of disorders of consciousness has also been hampered by heterogeneity of study designs, variables, and outcomes, leading to results that are not comparable for evidence synthesis. The different backgrounds of professionals caring for patients with disorders of consciousness and the different goals at different stages of care could partly explain this variability. The Prospective Studies working group of the Neurocritical Care Society Curing Coma Campaign was established to create a platform for observational studies and future clinical trials on disorders of consciousness and coma across the continuum of care. In this narrative review, the author panel presents limitations of prior observational clinical research and outlines practical considerations for future investigations. A narrative review format was selected to ensure that the full breadth of study design considerations could be addressed and to facilitate a future consensus-based statement (e.g. via a modified Delphi) and series of recommendations. The panel convened weekly online meetings from October 2021 to December 2022. Research considerations addressed the nosographic status of disorders of consciousness, case ascertainment and verification, selection of dependent variables, choice of covariates and measurement and analysis of outcomes and covariates, aiming to promote more homogeneous designs and practices in future observational studies. The goal of this review is to inform a broad community of professionals with different backgrounds and clinical interests to address the methodological challenges imposed by the transition of care from acute to chronic stages and to streamline data gathering for patients with disorders of consciousness. A coordinated effort will be a key to allow reliable observational data synthesis and epidemiological estimates and ultimately inform condition-modifying clinical trials.
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Affiliation(s)
- Lorenzo Tinti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan 20156, Italy
| | - Thomas Lawson
- Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Erika Molteni
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EU, UK
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
| | - Tarek Sharshar
- Neuro-Intensive Care Medicine, Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris 75006, France
| | - Yelena G Bodien
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
| | - Susanne Muehlschlegel
- Department of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke’s Medical Center, Houston, TX 77030, USA
| | - Paul M Vespa
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge CB2 1TN, UK
| | - Giuseppe Citerio
- NeuroIntensive Care, IRCSS Fondazione San Gerardo dei Tintori, Monza 20900, Italy
- School of Medicine and Surgery, Università Milano Bicocca, Milan 20854, Italy
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
- Department of Neurology, Johannes Kepler University, Linz 4040, Austria
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH 43210, USA
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24
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Morris H, Kaplan PW, Kane N. Electroencephalography in encephalopathy and encephalitis. Pract Neurol 2024; 24:2-10. [PMID: 38050141 DOI: 10.1136/pn-2023-003798] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2023] [Indexed: 12/06/2023]
Abstract
Electroencephalography (EEG) is a useful adjunct to clinical neurological examination, particularly as it may detect subtle or subclinical disturbance of cerebral function and it allows monitoring of cerebral activity over time. Continuous EEG combined with quantitative analysis and machine learning may help identify changes in real time, before the emergence of clinical signs and response to interventions. EEG is rarely pathognomonic in encephalopathy/encephalitis but when interpreted correctly and within the clinical context, certain phenotypes may indicate a specific pathophysiology (eg, lateralised periodic discharges in HSV-1, generalised periodic discharges in sporadic Creutzfeldt-Jakob disease, and extreme delta brushes in anti-n-methyl-D-aspartate receptor autoimmune encephalitis). EEG is included in some specialist guidelines for disease assessment, monitoring and prognostication (ie, hepatic, cancer immunotherapy, viral, prion, autoimmune encephalitis and hypoxic ischaemic encephalopathy). EEG is invaluable for confirming or excluding non-convulsive seizures or status epilepticus, particularly in critically ill patients, and in understanding new concepts such as epileptic encephalopathy and the ictal-interictal continuum.
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Affiliation(s)
- Hollie Morris
- Grey Walter Dept of Clinical Neurophysiology, North Bristol NHS Trust, Bristol, UK
| | - Peter W Kaplan
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Nick Kane
- Grey Walter Dept of Clinical Neurophysiology, North Bristol NHS Trust, Westbury on Trym, UK
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25
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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26
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Rossetti AO, Claassen J, Gaspard N. Status epilepticus in the ICU. Intensive Care Med 2024; 50:1-16. [PMID: 38117319 DOI: 10.1007/s00134-023-07263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
Status epilepticus (SE) is a common medical emergency associated with significant morbidity and mortality. Management that follows published guidelines is best suited to improve outcomes, with the most severe cases frequently being managed in the intensive care unit (ICU). Diagnosis of convulsive SE can be made without electroencephalography (EEG), but EEG is required to reliably diagnose nonconvulsive SE. Rapidly narrowing down underlying causes for SE is crucial, as this may guide additional management steps. Causes may range from underlying epilepsy to acute brain injuries such as trauma, cardiac arrest, stroke, and infections. Initial management consists of rapid administration of benzodiazepines and one of the following non-sedating intravenous antiseizure medications (ASM): (fos-)phenytoin, levetiracetam, or valproate; other ASM are increasingly used, such as lacosamide or brivaracetam. SE that continues despite these medications is called refractory, and most commonly treated with continuous infusions of midazolam or propofol. Alternatives include further non-sedating ASM and non-pharmacologic approaches. SE that reemerges after weaning or continues despite management with propofol or midazolam is labeled super-refractory SE. At this step, management may include non-sedating or sedating compounds including ketamine and barbiturates. Continuous video EEG is necessary for the management of refractory and super-refractory SE, as these are almost always nonconvulsive. If possible, management of the underlying cause of seizures is crucial particularly for patients with autoimmune encephalitis. Short-term mortality ranges from 10 to 15% after SE and is primarily related to increasing age, underlying etiology, and medical comorbidities. Refractoriness of treatment is clearly related to outcome with mortality rising from 10% in responsive cases, to 25% in refractory, and nearly 40% in super-refractory SE.
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Affiliation(s)
- Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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Turella S, Dankiewicz J, Friberg H, Jakobsen JC, Leithner C, Levin H, Lilja G, Moseby-Knappe M, Nielsen N, Rossetti AO, Sandroni C, Zubler F, Cronberg T, Westhall E. The predictive value of highly malignant EEG patterns after cardiac arrest: evaluation of the ERC-ESICM recommendations. Intensive Care Med 2024; 50:90-102. [PMID: 38172300 PMCID: PMC10811097 DOI: 10.1007/s00134-023-07280-9] [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: 06/22/2023] [Accepted: 11/14/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE The 2021 guidelines endorsed by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) recommend using highly malignant electroencephalogram (EEG) patterns (HMEP; suppression or burst-suppression) at > 24 h after cardiac arrest (CA) in combination with at least one other concordant predictor to prognosticate poor neurological outcome. We evaluated the prognostic accuracy of HMEP in a large multicentre cohort and investigated the added value of absent EEG reactivity. METHODS This is a pre-planned prognostic substudy of the Targeted Temperature Management trial 2. The presence of HMEP and background reactivity to external stimuli on EEG recorded > 24 h after CA was prospectively reported. Poor outcome was measured at 6 months and defined as a modified Rankin Scale score of 4-6. Prognostication was multimodal, and withdrawal of life-sustaining therapy (WLST) was not allowed before 96 h after CA. RESULTS 845 patients at 59 sites were included. Of these, 579 (69%) had poor outcome, including 304 (36%) with WLST due to poor neurological prognosis. EEG was recorded at a median of 71 h (interquartile range [IQR] 52-93) after CA. HMEP at > 24 h from CA had 50% [95% confidence interval [CI] 46-54] sensitivity and 93% [90-96] specificity to predict poor outcome. Specificity was similar (93%) in 541 patients without WLST. When HMEP were unreactive, specificity improved to 97% [94-99] (p = 0.008). CONCLUSION The specificity of the ERC-ESICM-recommended EEG patterns for predicting poor outcome after CA exceeds 90% but is lower than in previous studies, suggesting that large-scale implementation may reduce their accuracy. Combining HMEP with an unreactive EEG background significantly improved specificity. As in other prognostication studies, a self-fulfilling prophecy bias may have contributed to observed results.
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Affiliation(s)
- Sara Turella
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Capital Region, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Christoph Leithner
- Department of Neurology and Experimental Neurology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Helena Levin
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
- Skane University Hospital, Lund, Sweden
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology and Rehabilitation, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesiology and Intensive Care Medicine, Helsingborg Hospital, Helsingborg, Sweden
| | - Andrea O Rossetti
- Department of Neurology, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Frédéric Zubler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | - Erik Westhall
- Department of Clinical Sciences, Clinical Neurophysiology, Lund University, S-221 85, Lund, Sweden.
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Stancati JA, Owyang CG, Araos JD, Agarwal S, Grossestreuer AV, Counts CR, Johnson NJ, Morgan RW, Moskowitz A, Perman SM, Sawyer KN, Yuriditsky E, Horowitz JM, Kaviyarasu A, Palasz J, Abella BS, Teran F. The Latest in Resuscitation Research: Highlights From the 2022 American Heart Association's Resuscitation Science Symposium. J Am Heart Assoc 2023; 12:e031530. [PMID: 38038192 PMCID: PMC10727320 DOI: 10.1161/jaha.123.031530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
BACKGROUND Every year the American Heart Association's Resuscitation Science Symposium (ReSS) brings together a community of international resuscitation science researchers focused on advancing cardiac arrest care. METHODS AND RESULTS The American Heart Association's ReSS was held in Chicago, Illinois from November 4th to 6th, 2022. This annual narrative review summarizes ReSS programming, including awards, special sessions and scientific content organized by theme and plenary session. CONCLUSIONS By exploring both the science of resuscitation and important related topics including survivorship, disparities, and community-focused programs, this meeting provided important resuscitation updates.
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Affiliation(s)
| | - Clark G. Owyang
- Department of Emergency MedicineWeill Cornell Medicine/New York Presbyterian HospitalNew YorkNYUSA
- Division of Pulmonary and Critical Care MedicineWeill Cornell Medicine/New York Presbyterian HospitalNew YorkNYUSA
| | - Joaquin D. Araos
- Department of Clinical Sciences, College of Veterinary MedicineCornell UniversityIthacaNYUSA
| | - Sachin Agarwal
- Division of Neurocritical Care & Hospitalist NeurologyColumbia University Irving Medical CenterNew YorkNYUSA
| | | | | | - Nicholas J. Johnson
- Department of Emergency MedicineUniversity of WashingtonSeattleWAUSA
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of WashingtonSeattleWAUSA
| | - Ryan W. Morgan
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care MedicineChildren’s Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Ari Moskowitz
- Division of Critical Care MedicineMontefiore Medical CenterBronxNYUSA
| | - Sarah M. Perman
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Kelly N. Sawyer
- Department of Emergency MedicineUniversity of PittsburghPittsburghPAUSA
| | - Eugene Yuriditsky
- Division of Cardiology, Department of MedicineNYU Langone HealthNew YorkNYUSA
| | - James M. Horowitz
- Division of Cardiology, Department of MedicineNYU Langone HealthNew YorkNYUSA
| | - Aarthi Kaviyarasu
- Department of Emergency Medicine, Center for Resuscitation ScienceUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Joanna Palasz
- Department of Emergency MedicineWeill Cornell Medicine/New York Presbyterian HospitalNew YorkNYUSA
| | - Benjamin S. Abella
- Department of Emergency Medicine, Center for Resuscitation ScienceUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Felipe Teran
- Department of Emergency MedicineWeill Cornell Medicine/New York Presbyterian HospitalNew YorkNYUSA
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29
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Amorim E, Zheng WL, Ghassemi MM, Aghaeeaval M, Kandhare P, Karukonda V, Lee JW, Herman ST, Sivaraju A, Gaspard N, Hofmeijer J, van Putten MJAM, Sameni R, Reyna MA, Clifford GD, Westover MB. The International Cardiac Arrest Research Consortium Electroencephalography Database. Crit Care Med 2023; 51:1802-1811. [PMID: 37855659 PMCID: PMC10841086 DOI: 10.1097/ccm.0000000000006074] [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] [Indexed: 10/20/2023]
Abstract
OBJECTIVES To develop the International Cardiac Arrest Research (I-CARE), a harmonized multicenter clinical and electroencephalography database for acute hypoxic-ischemic brain injury research involving patients with cardiac arrest. DESIGN Multicenter cohort, partly prospective and partly retrospective. SETTING Seven academic or teaching hospitals from the United States and Europe. PATIENTS Individuals 16 years old or older who were comatose after return of spontaneous circulation following a cardiac arrest who had continuous electroencephalography monitoring were included. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS Clinical and electroencephalography data were harmonized and stored in a common Waveform Database-compatible format. Automated spike frequency, background continuity, and artifact detection on electroencephalography were calculated with 10-second resolution and summarized hourly. Neurologic outcome was determined at 3-6 months using the best Cerebral Performance Category (CPC) scale. This database includes clinical data and 56,676 hours (3.9 terabytes) of continuous electroencephalography data for 1,020 patients. Most patients died ( n = 603, 59%), 48 (5%) had severe neurologic disability (CPC 3 or 4), and 369 (36%) had good functional recovery (CPC 1-2). There is significant variability in mean electroencephalography recording duration depending on the neurologic outcome (range, 53-102 hr for CPC 1 and CPC 4, respectively). Epileptiform activity averaging 1 Hz or more in frequency for at least 1 hour was seen in 258 patients (25%) (19% for CPC 1-2 and 29% for CPC 3-5). Burst suppression was observed for at least 1 hour in 207 (56%) and 635 (97%) patients with CPC 1-2 and CPC 3-5, respectively. CONCLUSIONS The I-CARE consortium electroencephalography database provides a comprehensive real-world clinical and electroencephalography dataset for neurophysiology research of comatose patients after cardiac arrest. This dataset covers the spectrum of abnormal electroencephalography patterns after cardiac arrest, including epileptiform patterns and those in the ictal-interictal continuum.
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Affiliation(s)
- Edilberto Amorim
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wei-Long Zheng
- Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, CN
| | - Mohammad M. Ghassemi
- Department of Computer Science and Engineering, Michigan State University, East Lansing, Michigan, USA
| | - Mahsa Aghaeeaval
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Pravinkumar Kandhare
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Vishnu Karukonda
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Susan T. Herman
- Department of Neurology, Barrow Neurological Institute, Comprehensive Epilepsy Center, Phoenix, Arizona, USA
| | - Adithya Sivaraju
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nicolas Gaspard
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Neurology, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jeannette Hofmeijer
- Clinical Neurophysiology Group, University of Twente, Enschede, The Netherlands
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michel J. A. M. van Putten
- Clinical Neurophysiology Group, University of Twente, Enschede, The Netherlands
- Department of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, The Netherlands
| | - Reza Sameni
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Matthew A. Reyna
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Gari D. Clifford
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, Georgia, USA
| | - M. Brandon Westover
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Nakamichi Y, Ichibayashi R, Watanabe M, Suzuki G, Serizawa H, Yamamoto S, Masuyama Y, Honda M. Improved Neurological Outcome of Perampanel for Hypoxic-Ischemic Encephalopathy in Patients After Out-of-Hospital Cardiac Arrest Resuscitation. Cureus 2023; 15:e51392. [PMID: 38292945 PMCID: PMC10826245 DOI: 10.7759/cureus.51392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Although the resuscitation rate for out-of-hospital cardiac arrest (OHCA) patients in Japan is increasing due to the widespread use of automated external defibrillators, the proportion of patients who can return to society remains low at approximately 7%. Many patients have poor neurological outcomes and cannot return to society because of post-resuscitation hypoxic-ischemic encephalopathy. While the resumption of cardiac rhythm is important for patients with OHCA, improving neurological outcomes and returning to society are also important. OBJECTIVES To investigate whether perampanel, an antiepileptic drug that provides neurological protection against stroke and head injury, could improve neurological outcomes in patients resuscitated after OHCA. METHODS The participants included 33 patients with OHCA admitted to our hospital from January 2021 to June 2022 and 33 patients admitted before that time. Perampanel was administered to the patients in the intervention group immediately after resuscitation. We defined a Cerebral Performance Category (CPC) score of 1.2 as a good neurological outcome. RESULTS There was no significant difference in neurological outcomes at intensive care unit discharge between the intervention and non-intervention groups (number of CPC 1.2: 16/33 vs. 9/33); however, neurological outcomes at hospital discharge were significantly better in the intervention group (number of CPC 1.2: 19/33 vs. 9/33 P = 0.01). CONCLUSION The α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate receptor inhibitory and neuronal protective effects of perampanel may have inhibited the progression of hypoxic-ischemic encephalopathy, which develops after the resumption of cardiac rhythm, and suppressed neuronal damage. Early administration of perampanel after resuscitation of patients with OHCA may improve neurological outcomes.
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Affiliation(s)
- Yoshimi Nakamichi
- Emergency Medicine, Toho University Medical Center Omori Hospital, Tokyo, JPN
| | - Ryo Ichibayashi
- Internal Medicine, Toho University Medical Center Sakura Hospital, Chiba, JPN
| | - Masayuki Watanabe
- Emergency Medicine, Toho University Medical Center Omori Hospital, Tokyo, JPN
| | - Ginga Suzuki
- Emergency Medicine, Toho University Medical Center Omori Hospital, Tokyo, JPN
| | - Hibiki Serizawa
- Emergency Medicine, Toho University Medical Center Omori Hospital, Tokyo, JPN
| | - Saki Yamamoto
- Emergency Medicine, Toho University Medical Center Omori Hospital, Tokyo, JPN
| | - Yuka Masuyama
- Emergency Medicine, Toho University Medical Center Omori Hospital, Tokyo, JPN
| | - Mitsuru Honda
- Emergency Medicine, Toho University Medical Center Omori Hospital, Tokyo, JPN
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Orav K, Bosque Varela P, Prüwasser T, Machegger L, Leitinger M, Trinka E, Kuchukhidze G. Post-hypoxic status epilepticus - A distinct subtype of status epilepticus with poor prognosis. Epileptic Disord 2023; 25:823-832. [PMID: 37776308 PMCID: PMC10947449 DOI: 10.1002/epd2.20164] [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: 06/20/2023] [Revised: 08/31/2023] [Accepted: 09/23/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVE To evaluate the clinical outcome of patients with possible and definitive post-hypoxic status epilepticus (SE) and to describe the SE types in patients with definitive post-hypoxic SE. METHODS Patients with definitive or possible SE resulting from hypoxic brain injury after cardiac arrest (CA) were prospectively recruited. Intermittent EEG was used for the diagnosis of SE according to clinical practice. Two raters blinded to outcome analyzed EEGs retrospectively for possible and definitive SE patterns and background features (frequency, continuity, reactivity, and voltage). Definitive SE was classified according to semiology (ILAE). Mortality and Cerebral Performance Categories (CPC) score were evaluated 1 month after CA. RESULTS We included 64 patients of whom 92% died. Among the survivors, only one patient had a good neurological outcome (CPC 1). No patient survived with a burst suppression pattern, low voltage, or electro-cerebral silence in any EEG. Possible or definitive SE was diagnosed in a median of 47 h (IQR 39-72 h) after CA. EEG criteria for definitive electrographic SE were fulfilled in 39% of patients; in 38% - for electroclinical SE and in 23% - for ictal-interictal continuum (IIC). The outcome did not differ significantly between the three groups. The only patient with good functional outcome belonged to the IIC group. Comatose non-convulsive SE (NCSE) without subtle motor phenomenon occurred in 20% of patients with definitive electrographic SE and outcome was similar to other types of SE. SIGNIFICANCE Possible or definitive SE due to hypoxic brain injury is associated with poor prognosis. The outcome of patients with electrographic SE, electroclinical SE, and IIC did not differ significantly. Outcome was similar in patients with definitive electrographic SE with and without prominent motor features.
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Affiliation(s)
- Kateriine Orav
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
- Department of NeurologyNorth Estonia Medical CentreTallinnEstonia
| | - Pilar Bosque Varela
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
| | - Tanja Prüwasser
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
- Department of MathematicsParis‐Lodron UniversitySalzburgAustria
| | - Lukas Machegger
- Department of Neuroradiology, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
| | - Markus Leitinger
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
| | - Eugen Trinka
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
- Neuroscience InstituteChristian Doppler University HospitalSalzburgAustria
- Karl Landsteiner Institute for Neurorehabilitation and Space NeurologySalzburgAustria
| | - Giorgi Kuchukhidze
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
- Neuroscience InstituteChristian Doppler University HospitalSalzburgAustria
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Behringer W, Skrifvars MB, Taccone FS. Postresuscitation management. Curr Opin Crit Care 2023; 29:640-647. [PMID: 37909369 DOI: 10.1097/mcc.0000000000001116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
PURPOSE OF REVIEW To describe the most recent scientific evidence on ventilation/oxygenation, circulation, temperature control, general intensive care, and prognostication after successful resuscitation from adult cardiac arrest. RECENT FINDINGS Targeting a lower oxygen target (90-94%) is associated with adverse outcome. Targeting mild hypercapnia is not associated with improved functional outcomes or survival. There is no compelling evidence supporting improved outcomes associated with a higher mean arterial pressure target compared to a target of >65 mmHg. Noradrenalin seems to be the preferred vasopressor. A low cardiac index is common over the first 24 h but aggressive fluid loading and the use of inotropes are not associated with improved outcome. Several meta-analyses of randomized clinical trials show conflicting results whether hypothermia in the 32-34°C range as compared to normothermia or no temperature control improves functional outcome. The role of sedation is currently under evaluation. Observational studies suggest that the use of neuromuscular blockade may be associated with improved survival and functional outcome. Prophylactic antibiotic does not impact on outcome. No single predictor is entirely accurate to determine neurological prognosis. The presence of at least two predictors of severe neurological injury indicates that an unfavorable neurological outcome is very likely. SUMMARY Postresuscitation care aims for normoxemia, normocapnia, and normotension. The optimal target core temperature remains a matter of debate, whether to implement temperature management within the 32-34°C range or focus on fever prevention, as recommended in the latest European Resuscitation Council/European Society of Intensive Care Medicine guidelines Prognostication of neurological outcome demands a multimodal approach.
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Affiliation(s)
- Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
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Bhatti KS, Rajagopalan S. Case report: Invasive neuromonitoring in status epilepticus induced hypoxic ischemic brain injury. Front Neurol 2023; 14:1284098. [PMID: 38099068 PMCID: PMC10720614 DOI: 10.3389/fneur.2023.1284098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/08/2023] [Indexed: 12/17/2023] Open
Abstract
Objectives Literature on invasive neuromonitoring and bilateral decompressive craniectomies (BDC) in patients with refractory status epilepticus (RSE)-mediated hypoxic-ischemic brain injury (HIBI) is limited. Neuromonitoring can guide decision making and treatment escalation. Methods and results We report a case of a 17 years-old male who was admitted to our hospital's intensive care unit for RSE. HIBI was detected on neuroimaging on this patient's second day of admission after he developed central diabetes insipidus (DI). Invasive neuromonitoring revealed raised intracranial pressure (ICP) and brain hypoxia as measured by reduced brain tissue oxygen tension (PbtO2). Treatments were escalated in a tiered fashion, including administration of hyperosmolar agents, analgesics, sedatives, and a neuromuscular blocking drug. Eventually, BDC was performed as a salvage therapy as a means of controlling refractory ICP crisis in the setting of diffuse cerebral edema (DCE) following HIBI. Discussion SE-mediated HIBI can result in refractory ICP crisis. Neuromonitoring can help identify secondary brain injury (SBI), guide treatment strategies, including surgical interventions, and may lead to better outcomes.
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Htet NN, Jafari D, Walker JA, Pourmand A, Shaw A, Dinh K, Tran QK. Trend of Outcome Metrics in Recent Out-of-Hospital-Cardiac-Arrest Research: A Narrative Review of Clinical Trials. J Clin Med 2023; 12:7196. [PMID: 38002808 PMCID: PMC10672249 DOI: 10.3390/jcm12227196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management.
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Affiliation(s)
- Natalie N. Htet
- Department of Emergency Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Daniel Jafari
- Donald and Barbara Zucker School of Medicine Hofstra Northwell, Hempstead, NY 11549, USA;
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Jennifer A. Walker
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX 76104, USA;
- Department of Emergency Medicine, Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA;
| | - Anna Shaw
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Khai Dinh
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Quincy K. Tran
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Long B, Koyfman A. Nonconvulsive Status Epilepticus: A Review for Emergency Clinicians. J Emerg Med 2023; 65:e259-e271. [PMID: 37661524 DOI: 10.1016/j.jemermed.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/01/2023] [Accepted: 05/26/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Status epilepticus is associated with significant morbidity and mortality and is divided into convulsive status epilepticus and nonconvulsive status epilepticus (NCSE). OBJECTIVE This review provides a focused evaluation of NCSE for emergency clinicians. DISCUSSION NCSE is a form of status epilepticus presenting with prolonged seizure activity. This disease is underdiagnosed, as it presents with nonspecific signs and symptoms, most commonly change in mental status without overt convulsive motor activity. Causes include epilepsy, cerebral pathology or injury, any systemic insult such as infection, and drugs or toxins. Mortality is primarily related to the underlying condition. Patients most commonly present with altered mental status, but other signs and symptoms include abnormal ocular movements and automatisms such as lip smacking or subtle motor twitches in the face or extremities. The diagnosis is divided into electrographic and electroclinical, and although electroencephalogram (EEG) is recommended for definitive diagnosis, emergency clinicians should consider this disease in patients with prolonged postictal state after a seizure with no improvement in mental status, altered mental status with acute cerebral pathology (e.g., stroke, hypoxic brain injury), and unexplained altered mental status. Assessment includes laboratory evaluation and neuroimaging with EEG. Management includes treating life-threatening conditions, including compromise of the airway, hypoglycemia, hyponatremia, and hypo- or hyperthermia, followed by rapid cessation of the seizure activity with benzodiazepines and other antiseizure medications. CONCLUSIONS An understanding of the presentation and management of NCSE can assist emergency clinicians in the care of these patients.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Rubinos C, Bruzzone MJ, Viswanathan V, Figueredo L, Maciel CB, LaRoche S. Electroencephalography as a Biomarker of Prognosis in Acute Brain Injury. Semin Neurol 2023; 43:675-688. [PMID: 37832589 DOI: 10.1055/s-0043-1775816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Electroencephalography (EEG) is a noninvasive tool that allows the monitoring of cerebral brain function in critically ill patients, aiding with diagnosis, management, and prognostication. Specific EEG features have shown utility in the prediction of outcomes in critically ill patients with status epilepticus, acute brain injury (ischemic stroke, intracranial hemorrhage, subarachnoid hemorrhage, and traumatic brain injury), anoxic brain injury, and toxic-metabolic encephalopathy. Studies have also found an association between particular EEG patterns and long-term functional and cognitive outcomes as well as prediction of recovery of consciousness following acute brain injury. This review summarizes these findings and demonstrates the value of utilizing EEG findings in the determination of prognosis.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Vyas Viswanathan
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
| | - Lorena Figueredo
- Department of Neurology, University of Florida, Gainesville, Florida
| | - Carolina B Maciel
- Department of Neurology, University of Florida, Gainesville, Florida
| | - Suzette LaRoche
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
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Amorim E, Zheng WL, Jing J, Ghassemi MM, Lee JW, Wu O, Herman ST, Pang T, Sivaraju A, Gaspard N, Hirsch L, Ruijter BJ, Tjepkema-Cloostermans MC, Hofmeijer J, van Putten MJAM, Westover MB. Neurophysiology State Dynamics Underlying Acute Neurologic Recovery After Cardiac Arrest. Neurology 2023; 101:e940-e952. [PMID: 37414565 PMCID: PMC10501085 DOI: 10.1212/wnl.0000000000207537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 05/04/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Epileptiform activity and burst suppression are neurophysiology signatures reflective of severe brain injury after cardiac arrest. We aimed to delineate the evolution of coma neurophysiology feature ensembles associated with recovery from coma after cardiac arrest. METHODS Adults in acute coma after cardiac arrest were included in a retrospective database involving 7 hospitals. The combination of 3 quantitative EEG features (burst suppression ratio [BSup], spike frequency [SpF], and Shannon entropy [En]) was used to define 5 distinct neurophysiology states: epileptiform high entropy (EHE: SpF ≥4 per minute and En ≥5); epileptiform low entropy (ELE: SpF ≥4 per minute and <5 En); nonepileptiform high entropy (NEHE: SpF <4 per minute and ≥5 En); nonepileptiform low entropy (NELE: SpF <4 per minute and <5 En), and burst suppression (BSup ≥50% and SpF <4 per minute). State transitions were measured at consecutive 6-hour blocks between 6 and 84 hours after return of spontaneous circulation. Good neurologic outcome was defined as best cerebral performance category 1-2 at 3-6 months. RESULTS One thousand thirty-eight individuals were included (50,224 hours of EEG), and 373 (36%) had good outcome. Individuals with EHE state had a 29% rate of good outcome, while those with ELE had 11%. Transitions out of an EHE or BSup state to an NEHE state were associated with good outcome (45% and 20%, respectively). No individuals with ELE state lasting >15 hours had good recovery. DISCUSSION Transition to high entropy states is associated with an increased likelihood of good outcome despite preceding epileptiform or burst suppression states. High entropy may reflect mechanisms of resilience to hypoxic-ischemic brain injury.
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Affiliation(s)
- Edilberto Amorim
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands.
| | - Wei-Long Zheng
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Jin Jing
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Mohammad M Ghassemi
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Jong Woo Lee
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Ona Wu
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Susan T Herman
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Trudy Pang
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Adithya Sivaraju
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Nicolas Gaspard
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Lawrence Hirsch
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Barry J Ruijter
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Marleen C Tjepkema-Cloostermans
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Jeannette Hofmeijer
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - Michel J A M van Putten
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
| | - M Brandon Westover
- From the Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California, San Francisco; Department of Neurology (E.A., W.-L.Z., J.J., M.B.W.), Massachusetts General Hospital, Boston; Department of Computer Science and Engineering (W.-L.Z.), Shanghai Jiao Tong University, China; Department of Neurology (J.J., T.P., M.B.W.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Computer Science and Engineering (M.M.G.), Michigan State University, East Lansing; Department of Neurology (J.W.L.), Brigham and Women's Hospital; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Department of Radiology, Massachusetts General Hospital, Boston; Department of Neurology (S.T.H.), Barrow Neurological Institute Comprehensive Epilepsy Center, Phoenix, AZ; Department of Neurology (A.S., N.G., L.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.G.), Universite Libre de Bruxelles, Belgium; Clinical Neurophysiology Group (B.J.R., M.C.T.-C., J.H., M.J.A.M.v.P.), University of Twente, Enschede; Department of Neurology (J.H.), Rijnstate Hospital, Arnhem; and Department of Neurology and Clinical Neurophysiology (M.J.A.M.v.P.), Medisch Spectrum Twente, Enschede, the Netherlands
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Amorim E, Zheng WL, Ghassemi MM, Aghaeeaval M, Kandhare P, Karukonda V, Lee JW, Herman ST, Sivaraju A, Gaspard N, Hofmeijer J, van Putten MJAM, Sameni R, Reyna MA, Clifford GD, Westover MB. The International Cardiac Arrest Research (I-CARE) Consortium Electroencephalography Database. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.28.23294672. [PMID: 37693458 PMCID: PMC10491275 DOI: 10.1101/2023.08.28.23294672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Objective To develop a harmonized multicenter clinical and electroencephalography (EEG) database for acute hypoxic-ischemic brain injury research involving patients with cardiac arrest. Design Multicenter cohort, partly prospective and partly retrospective. Setting Seven academic or teaching hospitals from the U.S. and Europe. Patients Individuals aged 16 or older who were comatose after return of spontaneous circulation following a cardiac arrest who had continuous EEG monitoring were included. Interventions not applicable. Measurements and Main Results Clinical and EEG data were harmonized and stored in a common Waveform Database (WFDB)-compatible format. Automated spike frequency, background continuity, and artifact detection on EEG were calculated with 10 second resolution and summarized hourly. Neurological outcome was determined at 3-6 months using the best Cerebral Performance Category (CPC) scale. This database includes clinical and 56,676 hours (3.9 TB) of continuous EEG data for 1,020 patients. Most patients died (N=603, 59%), 48 (5%) had severe neurological disability (CPC 3 or 4), and 369 (36%) had good functional recovery (CPC 1-2). There is significant variability in mean EEG recording duration depending on the neurological outcome (range 53-102h for CPC 1 and CPC 4, respectively). Epileptiform activity averaging 1 Hz or more in frequency for at least one hour was seen in 258 (25%) patients (19% for CPC 1-2 and 29% for CPC 3-5). Burst suppression was observed for at least one hour in 207 (56%) and 635 (97%) patients with CPC 1-2 and CPC 3-5, respectively. Conclusions The International Cardiac Arrest Research (I-CARE) consortium database provides a comprehensive real-world clinical and EEG dataset for neurophysiology research of comatose patients after cardiac arrest. This dataset covers the spectrum of abnormal EEG patterns after cardiac arrest, including epileptiform patterns and those in the ictal-interictal continuum.
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Affiliation(s)
- Edilberto Amorim
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wei-Long Zheng
- Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, CN
| | - Mohammad M. Ghassemi
- Department of Computer Science and Engineering, Michigan State University, East Lansing, Michigan, USA
| | - Mahsa Aghaeeaval
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Pravinkumar Kandhare
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Vishnu Karukonda
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Susan T. Herman
- Department of Neurology, Barrow Neurological Institute, Comprehensive Epilepsy Center, Phoenix, Arizona, USA
| | - Adithya Sivaraju
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nicolas Gaspard
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Neurology, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jeannette Hofmeijer
- Clinical Neurophysiology Group, University of Twente, Enschede, The Netherlands
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michel J. A. M. van Putten
- Clinical Neurophysiology Group, University of Twente, Enschede, The Netherlands
- Department of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, The Netherlands
| | - Reza Sameni
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Matthew A. Reyna
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Gari D. Clifford
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, Georgia, USA
| | - M. Brandon Westover
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Horn J, Admiraal M, Hofmeijer J. Diagnosis and management of seizures and myoclonus after cardiac arrest. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:525-531. [PMID: 37486703 DOI: 10.1093/ehjacc/zuad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Janneke Horn
- Department of Intensive care Medicine, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Neurosciences Institute, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marjolein Admiraal
- Neurosciences Institute, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Neurology and Clinical Neurophysiology, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Technical Medical Center, Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
- Department of Neurology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
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Kondziella D. Neuroprognostication after cardiac arrest: what the cardiologist should know. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:550-558. [PMID: 36866627 DOI: 10.1093/ehjacc/zuad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/04/2023]
Abstract
Two aspects are a key to mastering prognostication of comatose cardiac arrest survivors: a detailed knowledge about the clinical trajectories of consciousness recovery (or lack thereof) and the ability to correctly interpret the results of multimodal investigations, which include clinical examination, electroencephalography, neuroimaging, evoked potentials, and blood biomarkers. While the very good and the very poor ends of the clinical spectrum typically do not pose diagnostic challenges, the intermediate 'grey zone' of post-cardiac arrest encephalopathy requires cautious interpretation of the available information and sufficiently long clinical observation. Late recovery of coma patients with initially ambiguous diagnostic results is increasingly reported, as are unresponsive patients with various forms of residual consciousness, including so-called cognitive motor dissociation, rendering prognostication of post-anoxic coma highly complex. The aim of this paper is to provide busy clinicians with a high-yield, concise overview of neuroprognostication after cardiac arrest, emphasizing notable developments in the field since 2020.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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41
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Parikh H, Sun H, Amerineni R, Rosenthal ES, Volfovsky A, Rudin C, Westover MB, Zafar SF. How Many Patients Do You Need? Investigating Trial Designs for Anti-Seizure Treatment in Acute Brain Injury Patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.21.23294339. [PMID: 37662339 PMCID: PMC10473786 DOI: 10.1101/2023.08.21.23294339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Objectives Epileptiform activity (EA) worsens outcomes in patients with acute brain injuries (e.g., aneurysmal subarachnoid hemorrhage [aSAH]). Randomized trials (RCTs) assessing anti-seizure interventions are needed. Due to scant drug efficacy data and ethical reservations with placebo utilization, RCTs are lacking or hindered by design constraints. We used a pharmacological model-guided simulator to design and determine feasibility of RCTs evaluating EA treatment. Methods In a single-center cohort of adults (age >18) with aSAH and EA, we employed a mechanistic pharmacokinetic-pharmacodynamic framework to model treatment response using observational data. We subsequently simulated RCTs for levetiracetam and propofol, each with three treatment arms mirroring clinical practice and an additional placebo arm. Using our framework we simulated EA trajectories across treatment arms. We predicted discharge modified Rankin Scale as a function of baseline covariates, EA burden, and drug doses using a double machine learning model learned from observational data. Differences in outcomes across arms were used to estimate the required sample size. Results Sample sizes ranged from 500 for levetiracetam 7 mg/kg vs placebo, to >4000 for levetiracetam 15 vs. 7 mg/kg to achieve 80% power (5% type I error). For propofol 1mg/kg/hr vs. placebo 1200 participants were needed. Simulations comparing propofol at varying doses did not reach 80% power even at samples >1200. Interpretation Our simulations using drug efficacy show sample sizes are infeasible, even for potentially unethical placebo-control trials. We highlight the strength of simulations with observational data to inform the null hypotheses and assess feasibility of future trials of EA treatment.
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Affiliation(s)
| | - Haoqi Sun
- Beth Israel Deaconess Medical Center, Department of Neurology
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42
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Singh A, Jefferson J. Post-Cardiac Arrest Care. Emerg Med Clin North Am 2023; 41:617-632. [PMID: 37391254 DOI: 10.1016/j.emc.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
A structured approach to postcardiac arrest care is needed. Although immediate goals include obtaining a blood pressure reading and ECG immediately after return of spontaneous circulation, other more advanced goals include minimizing CNS injury, managing cardiovascular dysfunction, reducing systemic ischemic/reperfusion injury, and identifying and treating the underlying cause to the arrest. This article summarizes the current understanding of the hemodynamic, neurologic, and metabolic abnormalities encountered in postarrest patients.
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Affiliation(s)
- Amandeep Singh
- Department of Emergency Medicine, Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA.
| | - Jamal Jefferson
- Department of Emergency Medicine, Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA
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43
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Hoedemaekers C, Hofmeijer J, Horn J. Value of EEG in outcome prediction of hypoxic-ischemic brain injury in the ICU: A narrative review. Resuscitation 2023; 189:109900. [PMID: 37419237 DOI: 10.1016/j.resuscitation.2023.109900] [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: 04/24/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023]
Abstract
Prognostication of comatose patients after cardiac arrest aims to identify patients with a large probability of favourable or unfavouble outcome, usually within the first week after the event. Electroencephalography (EEG) is a technique that is increasingly used for this purpose and has many advantages, such as its non-invasive nature and the possibility to monitor the evolution of brain function over time. At the same time, use of EEG in a critical care environment faces a number of challenges. This narrative review describes the current role and future applications of EEG for outcome prediction of comatose patients with postanoxic encephalopathy.
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Affiliation(s)
- Cornelia Hoedemaekers
- Department of Critical Care, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands.
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands; Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Janneke Horn
- Department of Critical Care, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
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44
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Penketh J, Nolan JP. Post-Cardiac Arrest Syndrome. J Neurosurg Anesthesiol 2023; 35:260-264. [PMID: 37192474 DOI: 10.1097/ana.0000000000000921] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 04/06/2023] [Indexed: 05/18/2023]
Abstract
Post-cardiac arrest syndrome (PCAS) is a multicomponent entity affecting many who survive an initial period of resuscitation following cardiac arrest. This focussed review explores some of the strategies for mitigating the effects of PCAS following the return of spontaneous circulation. We consider the current evidence for controlled oxygenation, strategies for blood-pressure targets, the timing of coronary reperfusion, and the evidence for temperature control and treatment of seizures. Despite several large trials investigating specific strategies to improve outcomes after cardiac arrest, many questions remain unanswered. Results of some studies suggest that interventions may benefit specific subgroups of cardiac arrest patients, but the optimal timing and duration of many interventions remain unknown. The role of intracranial pressure monitoring has been the subject of only a few studies, and its benefits remain unclear. Research aimed at improving the management of PCAS is ongoing.
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Affiliation(s)
| | - Jerry P Nolan
- Intensive care unit, Royal United Hospital, Bath
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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45
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Elmer J, Maciel CB. Survivorship after post-anoxic cerebral hyperexcitability requires more than functional independence. Resuscitation 2023:109866. [PMID: 37302685 DOI: 10.1016/j.resuscitation.2023.109866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Jonathan Elmer
- Departments of Emergency Medicine, Critical Care Medicine and Neurology, University of Pittsburgh School of Medicine.
| | - Carolina B Maciel
- Departments of Neurology and Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA, 32611; Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Department of Neurology, University of Utah, Salt Lake City, UT, USA, 84132
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46
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Morris NA, Sarwal A. Neurologic Complications of Critical Medical Illness. Continuum (Minneap Minn) 2023; 29:848-886. [PMID: 37341333 DOI: 10.1212/con.0000000000001278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article reviews the neurologic complications encountered in patients admitted to non-neurologic intensive care units, outlines various scenarios in which a neurologic consultation can add to the diagnosis or management of a critically ill patient, and provides advice on the best diagnostic approach in the evaluation of these patients. LATEST DEVELOPMENTS Increasing recognition of neurologic complications and their adverse impact on long-term outcomes has led to increased neurology involvement in non-neurologic intensive care units. The COVID-19 pandemic has highlighted the importance of having a structured clinical approach to neurologic complications of critical illness as well as the critical care management of patients with chronic neurologic disabilities. ESSENTIAL POINTS Critical illness is often accompanied by neurologic complications. Neurologists need to be aware of the unique needs of critically ill patients, especially the nuances of the neurologic examination, challenges in diagnostic testing, and neuropharmacologic aspects of commonly used medications.
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47
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Wahlster S, Danielson K, Craft L, Matin N, Town JA, Srinivasan V, Schubert G, Carlbom D, Kim F, Johnson NJ, Tirschwell D. Factors Associated with Early Withdrawal of Life-Sustaining Treatments After Out-of-Hospital Cardiac Arrest: A Subanalysis of a Randomized Trial of Prehospital Therapeutic Hypothermia. Neurocrit Care 2023; 38:676-687. [PMID: 36380126 DOI: 10.1007/s12028-022-01636-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objective of this study is to describe incidence and factors associated with early withdrawal of life-sustaining therapies based on presumed poor neurologic prognosis (WLST-N) and practices around multimodal prognostication after out-of-hospital cardiac arrest (OHCA). METHODS We performed a subanalysis of a randomized controlled trial assessing prehospital therapeutic hypothermia in adult patients admitted to nine hospitals in King County with nontraumatic OHCA between 2007 and 2012. Patients who underwent tracheal intubation and were unconscious following return of spontaneous circulation were included. Our outcomes were (1) incidence of early WLST-N (WLST-N within < 72 h from return of spontaneous circulation), (2) factors associated with early WLST-N compared with patients who remained comatose at 72 h without WLST-N, (3) institutional variation in early WLST-N, (4) use of multimodal prognostication, and (5) use of sedative medications in patients with early WLST-N. Analysis included descriptive statistics and multivariable logistic regression. RESULTS We included 1,040 patients (mean age was 65 years, 37% were female, 41% were White, and 44% presented with arrest due to ventricular fibrillation) admitted to nine hospitals. Early WLST-N accounted for 24% (n = 154) of patient deaths and occurred in half (51%) of patients with WLST-N. Factors associated with early WLST-N in multivariate regressions were older age (odds ratio [OR] 1.02, 95% confidence interval [CI]: 1.01-1.03), preexisting do-not-attempt-resuscitation orders (OR 4.67, 95% CI: 1.55-14.01), bilateral absent pupillary reflexes (OR 2.4, 95% CI: 1.42-4.10), and lack of neurological consultation (OR 2.60, 95% CI: 1.52-4.46). The proportion of patients with early WLST-N among all OHCA admissions ranged from 19-60% between institutions. A head computed tomography scan was obtained in 54% (n = 84) of patients with early WLST-N; 22% (n = 34) and 5% (n = 8) underwent ≥ 1 and ≥ 2 additional prognostic tests, respectively. Prognostic tests were more frequently performed when neurological consultation occurred. Most patients received sedating medications (90%) within 24 h before early WLST-N; the median time from last sedation to early WLST-N was 4.2 h (interquartile range 0.4-15). CONCLUSIONS Nearly one quarter of deaths after OHCA were due to early WLST-N. The presence of concerning neurological examination findings appeared to impact early WLST-N decisions, even though these are not fully reliable in this time frame. Lack of neurological consultation was associated with early WLST-N and resulted in underuse of guideline-concordant multimodal prognostication. Sedating medications were often coadministered prior to early WLST-N and may have further confounded the neurological examination. Standardizing prognostication, restricting early WLST-N, and a multidisciplinary approach including neurological consultation might improve outcomes after OHCA.
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Affiliation(s)
- Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA.
- Department of Anesthesiology, University of Washington, Seattle, WA, USA.
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
| | - Kyle Danielson
- Airlift Northwest, University of Washington Medicine, Seattle, WA, USA
| | - Lindy Craft
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Nassim Matin
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
| | - James A Town
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Glenn Schubert
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
| | - David Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Francis Kim
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicholas J Johnson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - David Tirschwell
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
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van Gils PCW, Ruijter BJ, Bloo RJK, van Putten MJAM, Foudraine NA, van Hout MSE, Tromp SC, van Mook WNKA, Rouhl RPW, van Heugten CM, Hofmeijer J. Cognition, emotional state, and quality of life of survivors after cardiac arrest with rhythmic and periodic EEG patterns. Resuscitation 2023:109830. [PMID: 37182824 DOI: 10.1016/j.resuscitation.2023.109830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/16/2023]
Abstract
AIM Rhythmic and periodic patterns (RPPs) on the electroencephalogram (EEG) in comatose patients after cardiac arrest have been associated with high case fatality rates. A good neurological outcome according to the Cerebral Performance Categories (CPC) has been reported in up to 10% of cases. Data on cognitive, emotional, and quality of life outcomes are lacking. We aimed to provide insight into these outcomes at one-year follow-up. METHODS We assessed outcome of surviving comatose patients after cardiac arrest with RPPs included in the 'treatment of electroencephalographic status epilepticus after cardiopulmonary resuscitation' (TELSTAR) trial at one-year follow-up, including the CPC for functional neurological outcome, a cognitive assessment, the hospital anxiety and depression scale (HADS) for emotional outcomes, and the 36-item short-form health survey (SF-36) for quality of life. Cognitive impairment was defined as a score of more than 1.5 SD below the mean on ≥ 2 (sub)tests within a cognitive domain. RESULTS Fourteen patients were included (median age 58 years, 21% female), of whom 13 had a cognitive impairment. Eleven of 14 were impaired in memory, 9/14 in executive functioning, and 7/14 in attention. The median scores on the HADS and SF-36 were all worse than expected. Based on the CPC alone, 8/14 had a good outcome (CPC 1-2). CONCLUSION Nearly all cardiac arrest survivors with RPPs during the comatose state have cognitive impairments at one-year follow-up. The incidence of anxiety and depression symptoms seem relatively high and quality of life relatively poor, despite 'good' outcomes according to the CPC.
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Affiliation(s)
- Pauline C W van Gils
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands; Clinical Neurophysiology (CNPH), TechMed Centre, University of Twente, Enschede, the Netherlands; Limburg Brain Injury Center, Maastricht University, Maastricht, the Netherlands.
| | - Barry J Ruijter
- Clinical Neurophysiology (CNPH), TechMed Centre, University of Twente, Enschede, the Netherlands; Department of Neurology, OLVG, Amsterdam, the Netherlands
| | - Rubia J K Bloo
- Department of medical psychology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Michel J A M van Putten
- Clinical Neurophysiology (CNPH), TechMed Centre, University of Twente, Enschede, the Netherlands; Departments of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Norbert A Foudraine
- Department of Intensive Care, VieCuri Medical Center, Venlo, the Netherlands
| | | | - Selma C Tromp
- Departments of Neurology and Clinical Neurophysiology, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Walther N K A van Mook
- Department of Intensive Care Medicine, and Academy for Postgraduate Training, Maastricht University Medical Centre+; School of Health Professions Education, Maastricht University, the Netherlands
| | - Rob P W Rouhl
- Department of Neurology, Maastricht University Medical Centre+, the Netherlands; Academic Centre for Epileptology Kempenhaeghe/MUMC+, the Netherlands
| | - Caroline M van Heugten
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands; Limburg Brain Injury Center, Maastricht University, Maastricht, the Netherlands; Department of Neuropsychology and psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Jeannette Hofmeijer
- Clinical Neurophysiology (CNPH), TechMed Centre, University of Twente, Enschede, the Netherlands; Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
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49
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Fisch U, Jünger AL, Baumann SM, Semmlack S, De Marchis GM, Hunziker S, Rüegg S, Marsch S, Sutter R. Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus: A 9-Year Cohort Study. Neurology 2023; 100:e1955-e1966. [PMID: 36889924 PMCID: PMC10186226 DOI: 10.1212/wnl.0000000000207129] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/17/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate the frequency of induced EEG burst suppression pattern during continuous IV anesthesia (IVAD) and associated outcomes in adult patients treated for refractory status epilepticus (RSE). METHODS Patients with RSE treated with anesthetics at a Swiss academic care center from 2011 to 2019 were included. Clinical data and semiquantitative EEG analyses were assessed. Burst suppression was categorized as incomplete burst suppression (with ≥20% and <50% suppression proportion) or complete burst suppression (with ≥50% suppression proportion). The frequency of induced burst suppression and association of burst suppression with outcomes (persistent seizure termination, in-hospital survival, and return to premorbid neurologic function) were the endpoints. RESULTS We identified 147 patients with RSE treated with IVAD. Among 102 patients without cerebral anoxia, incomplete burst suppression was achieved in 14 (14%) with a median of 23 hours (interquartile range [IQR] 1-29) and complete burst suppression was achieved in 21 (21%) with a median of 51 hours (IQR 16-104). Age, Charlson comorbidity index, RSE with motor symptoms, the Status Epilepticus Severity Score and arterial hypotension requiring vasopressors were identified as potential confounders in univariable comparisons between patients with and without any burst suppression. Multivariable analyses revealed no associations between any burst suppression and the predefined endpoints. However, among 45 patients with cerebral anoxia, induced burst suppression was associated with persistent seizure termination (72% without vs 29% with burst suppression, p = 0.004) and survival (50% vs 14% p = 0.005). DISCUSSION In adult patients with RSE treated with IVAD, burst suppression with ≥50% suppression proportion was achieved in every fifth patient and not associated with persistent seizure termination, in-hospital survival, or return to premorbid neurologic function.
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Affiliation(s)
- Urs Fisch
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Anja L Jünger
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sira M Baumann
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Gian Marco De Marchis
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sabina Hunziker
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Rüegg
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Marsch
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Raoul Sutter
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland.
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Tewarie PKB, Tjepkema-Cloostermans MC, Abeysuriya RG, Hofmeijer J, van Putten MJAM. Preservation of thalamocortical circuitry is essential for good recovery after cardiac arrest. PNAS NEXUS 2023; 2:pgad119. [PMID: 37143862 PMCID: PMC10153639 DOI: 10.1093/pnasnexus/pgad119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/10/2023] [Accepted: 04/04/2023] [Indexed: 05/06/2023]
Abstract
Continuous electroencephalographam (EEG) monitoring contributes to prediction of neurological outcome in comatose cardiac arrest survivors. While the phenomenology of EEG abnormalities in postanoxic encephalopathy is well known, the pathophysiology, especially the presumed role of selective synaptic failure, is less understood. To further this understanding, we estimate biophysical model parameters from the EEG power spectra from individual patients with a good or poor recovery from a postanoxic encephalopathy. This biophysical model includes intracortical, intrathalamic, and corticothalamic synaptic strengths, as well as synaptic time constants and axonal conduction delays. We used continuous EEG measurements from hundred comatose patients recorded during the first 48 h postcardiac arrest, 50 with a poor neurological outcome [cerebral performance category ( CPC = 5 ) ] and 50 with a good neurological outcome ( CPC = 1 ). We only included patients that developed (dis-)continuous EEG activity within 48 h postcardiac arrest. For patients with a good outcome, we observed an initial relative excitation in the corticothalamic loop and corticothalamic propagation that subsequently evolved towards values observed in healthy controls. For patients with a poor outcome, we observed an initial increase in the cortical excitation-inhibition ratio, increased relative inhibition in the corticothalamic loop, delayed corticothalamic propagation of neuronal activity, and severely prolonged synaptic time constants that did not return to physiological values. We conclude that the abnormal EEG evolution in patients with a poor neurological recovery after cardiac arrest may result from persistent and selective synaptic failure that includes corticothalamic circuitry and also delayed corticothalamic propagation.
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Affiliation(s)
| | - Marleen C Tjepkema-Cloostermans
- Clinical Neurophysiology Group, University of Twente, 7522 NH Enschede, Netherlands
- Department of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, 7512 KZ Enschede, Netherlands
| | - Romesh G Abeysuriya
- Computational Epidemic Modelling, Burnet Institute, 3004 Melbourne, Australia
| | - Jeannette Hofmeijer
- Clinical Neurophysiology Group, University of Twente, 7522 NH Enschede, Netherlands
- Department of Neurology, Rijnstate Hospital, 6815 AD Arnhem, Netherlands
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