1
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Young MJ, Awad A, Andreev A, Bonkhoff AK, Schirmer MD, Dmytriw AA, Vranic JE, Rabinov JD, Doron O, Stapleton CJ, Das AS, Edlow BL, Singhal AB, Rost NS, Patel AB, Regenhardt RW. Characterizing coma in large vessel occlusion stroke. J Neurol 2024; 271:2658-2661. [PMID: 38366071 DOI: 10.1007/s00415-024-12199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/07/2024] [Accepted: 01/14/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Coma is an unresponsive state of disordered consciousness characterized by impaired arousal and awareness. The epidemiology and pathophysiology of coma in ischemic stroke has been underexplored. We sought to characterize the incidence and clinical features of coma as a presentation of large vessel occlusion (LVO) stroke. METHODS Individuals who presented with LVO were retrospectively identified from July 2018 to December 2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIHSS item 1a. RESULTS 28/637 (4.4%) patients with LVO stroke were identified as presenting with coma. The median NIHSS was 32 (IQR 29-34) for those with coma versus 11 (5-18) for those without (p < 0.0001). In coma, occlusion locations included basilar (13), vertebral (2), internal carotid (5), and middle cerebral (9) arteries. 8/28 were treated with endovascular thrombectomy (EVT), and 20/28 died during the admission. 65% of patients not treated with EVT had delayed presentations or large established infarcts. In models accounting for pre-stroke mRS, basilar occlusion location, intravenous thrombolysis, and EVT, coma independently increased the odds of transitioning to comfort care during admission (aOR 6.75; 95% CI 2.87,15.84; p < 0.001) and decreased the odds of 90-day mRS 0-2 (aOR 0.12; 95% CI 0.03,0.55; p = 0.007). CONCLUSIONS It is not uncommon for patients with LVO to present with coma, and delayed recognition of LVO can lead to poor outcomes, emphasizing the need for maintaining a high index of suspicion. While more commonly thought to result from posterior LVO, coma in our cohort was similarly likely to result from anterior LVO. Efforts to improve early diagnosis and care of patients with LVO presenting with coma are crucial.
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Affiliation(s)
- Michael J Young
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
| | - Amine Awad
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Alexander Andreev
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Anna K Bonkhoff
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Markus D Schirmer
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Brian L Edlow
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
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2
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Wu H, Lv W, Jiang L, Chen Z, Liang Q, Huang X, Zhong H, Qin P, Xie Q. Increased Adrenocorticotropic Hormone Levels Predict Recovery of Consciousness in Patients With Disorders of Consciousness. J Neurotrauma 2024. [PMID: 38517097 DOI: 10.1089/neu.2023.0501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
The potential influence of pituitary-related hormones (including both pituitary gland and target gland hormones) on functional recovery after traumatic brain injury has been observed. However, the relationship between these hormones and the recovery of consciousness in patients with disorders of consciousness (DOC) remains unclear. In this retrospective and observational study, 208 patients with DOC were recruited. According to the Glasgow Outcome Scale (GOS) scores after 6 months, patients with DOC were categorized into two subgroups: a favorable prognosis subgroup (n = 38) comprising those who regained consciousness (GOS score ≥3), and a poor prognosis subgroup (n = 156) comprising those who remained in DOC (GOS score <3). Comparative analyses of pituitary-related hormone levels between the two subgroups were conducted. Further, a binary logistic regression analysis was conducted to assess the predictive value of pituitary-related hormones for the patients' prognosis. The favorable prognosis subgroup showed a significant increase in adrenocorticotropic hormone (ACTH) levels (p = 0.036). Moreover, higher ACTH levels and shorter days since injury were significantly associated with a better prognosis, with odds ratios (ORs) of 0.928 (95% confidence interval [CI] = 0.873-0.985, p = 0.014) and 1.015 (95% CI = 1.005-1.026, p = 0.005), respectively. A subsequent receiver operating characteristic (ROC) analysis demonstrated the potential to predict patients' prognosis with an area under the curve value of 0.78, an overall accuracy of 75.5%, a sensitivity of 77.5%, and a specificity of 66.7%. Our findings indicate that ACTH levels could serve as a clinically valuable and convenient predictor for patients' prognosis.
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Affiliation(s)
- Hang Wu
- Key Laboratory of Brain, Cognition and Education Sciences, Ministry of Education, Institute for Brain Research and Rehabilitation, and Guangdong Key Laboratory of Mental Health and Cognitive Science, School of Psychology, South China Normal University, Guangzhou, China
| | - Wei Lv
- Department of Neurology, Affiliated Maoming People's Hospital, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangdong, China
| | - Liubei Jiang
- Center for Studies of Psychological Application, School of Psychology, South China Normal University, Guangzhou, China
| | - Zerong Chen
- Joint Research Center for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangdong, China
| | - Qimei Liang
- Joint Research Center for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangdong, China
| | - Xiyan Huang
- Joint Research Center for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangdong, China
| | - Haili Zhong
- Joint Research Center for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangdong, China
| | - Pengmin Qin
- Center for Studies of Psychological Application, School of Psychology, South China Normal University, Guangzhou, China
- Pazhou Lab, Guangzhou, China
| | - Qiuyou Xie
- Joint Research Center for Disorders of Consciousness, Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangdong, China
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3
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Ge Q, Lu H, Geng X, Chen X, Liu X, Sun H, Guo Z, Sun J, Qi F, Niu X, Wang A, He J, Sun W, Xu L. Serum metabolism alteration behind different etiology, diagnosis, and prognosis of disorders of consciousness. Chin Neurosurg J 2024; 10:12. [PMID: 38594757 PMCID: PMC11003070 DOI: 10.1186/s41016-024-00365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/26/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Patients with disorders of consciousness (DoC) exhibit varied revival outcomes based on different etiologies and diagnoses, the mechanisms of which remain largely unknown. The fluctuating clinical presentations in DoC pose challenges in accurately assessing consciousness levels and prognoses, often leading to misdiagnoses. There is an urgent need for a deeper understanding of the physiological changes in DoC and the development of objective diagnostic and prognostic biomarkers to improve treatment guidance. METHODS To explore biomarkers and understand the biological processes, we conducted a comprehensive untargeted metabolomic analysis on serum samples from 48 patients with DoC. Patients were categorized based on etiology (TBI vs. non-TBI), CRS-R scores, and prognosis. Advanced analytical techniques, including PCA and OPLS-DA models, were employed to identify differential metabolites. RESULTS Our analysis revealed a distinct separation in metabolomic profiles among the different groups. The primary differential metabolites distinguishing patients with varying etiologies were predominantly phospholipids, with a notable decrease in glycerophospholipids observed in the TBI group. Patients with higher CRS-R scores exhibited a pattern of impaired carbohydrate metabolism coupled with enhanced lipid metabolism. Notably, serum concentrations of both LysoPE and PE were reduced in patients with improved outcomes, suggesting their potential as prognostic biomarkers. CONCLUSIONS Our study underscores the critical role of phospholipid metabolism in the brain's metabolic alterations in patients with DoC. It identifies key biomarkers for diagnosis and prognosis, offering insights that could lead to novel therapeutic targets. These findings highlight the value of metabolomic profiling in understanding and potentially treating DoC.
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Affiliation(s)
- Qianqian Ge
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hezhen Lu
- China-Japan Union Hospital of Jilin University, Changchun, China
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xiaoli Geng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xueling Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Liu
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Haidan Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Zhengguang Guo
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jiameng Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Feng Qi
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Xia Niu
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Aiwei Wang
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Wei Sun
- Core Instrument Facility, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China.
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.
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Sampat V, Whitinger J, Flynn-O'Brien K, Kim I, Balakrishnan B, Mehta N, Sawdy R, Patel ND, Nallamothu R, Zhang L, Yan K, Zvara K, Farias-Moeller R. Accuracy of Early Neuroprognostication in Pediatric Severe Traumatic Brain Injury. Pediatr Neurol 2024; 155:36-43. [PMID: 38581727 DOI: 10.1016/j.pediatrneurol.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 02/15/2024] [Accepted: 03/12/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Children with severe traumatic brain injury (sTBI) are at risk for neurological sequelae impacting function. Clinicians are tasked with neuroprognostication to assist in decision-making. We describe a single-center study assessing clinicians' neuroprognostication accuracy. METHODS Clinicians of various specialties caring for children with sTBI were asked to predict their patients' functioning three to six months postinjury. Clinicians were asked to participate in the study if their patient had survived but not returned to baseline between day 4 and 7 postinjury. The outcome tool utilized was the functional status scale (FSS), ranging from 6 to 30 (best-worst function). Predicted scores were compared with actual scores three to six months postinjury. Lin concordance correlation coefficients were used to estimate agreement between predicted and actual FSS. Outcome was dichotomized as good (FSS 6 to 8) or poor (FSS ≥9). Positive and negative predictive values for poor outcome were calculated. Pessimistic prognostic prediction was defined as predicted worse outcome by ≥3 FSS points. Demographic and clinical variables were collected. RESULTS A total of 107 surveys were collected on 24 patients. Two children died. Fifteen children had complete (FSS = 6) or near-complete (FSS = 7) recovery. Mean predicted and actual FSS scores were 10.8 (S.D. 5.6) and 8.6 (S.D. 4.1), respectively. Predicted FSS scores were higher than actual scores (P < 0.001). Eight children had collective pessimistic prognostic prediction. CONCLUSIONS Clinicians predicted worse functional outcomes, despite high percentage of patients with near-normal function at follow-up clinic. Certain patient and provider factors were noted to impact accuracy and need to be studied in larger cohorts.
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Affiliation(s)
- Varun Sampat
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John Whitinger
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Katherine Flynn-O'Brien
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Irene Kim
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Binod Balakrishnan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Niyati Mehta
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rachel Sawdy
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Namrata D Patel
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rupa Nallamothu
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Liyun Zhang
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ke Yan
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kimberley Zvara
- Division of Pediatric Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Raquel Farias-Moeller
- Division of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
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5
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Ganesan SL. Combining Electrophysiology and Neuroimaging to Enhance Accuracy of Neuroprognostication in Children After Cardiac Arrest. Neurology 2024; 102:e209254. [PMID: 38350042 DOI: 10.1212/wnl.0000000000209254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/08/2024] [Indexed: 02/15/2024] Open
Affiliation(s)
- Saptharishi L Ganesan
- From the Department of Paediatrics (S.L.G.), Schulich School of Medicine & Dentistry, Western University, London; and Paediatric Critical Care Medicine (S.L.G.), Children's Hospital, London Health Sciences Centre, Ontario, Canada
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6
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Fischer D, Edlow BL. Coma Prognostication After Acute Brain Injury: A Review. JAMA Neurol 2024:2815829. [PMID: 38436946 DOI: 10.1001/jamaneurol.2023.5634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Importance Among the most impactful neurologic assessments is that of neuroprognostication, defined here as the prediction of neurologic recovery from disorders of consciousness caused by severe, acute brain injury. Across a range of brain injury etiologies, these determinations often dictate whether life-sustaining treatment is continued or withdrawn; thus, they have major implications for morbidity, mortality, and health care costs. Neuroprognostication relies on a diverse array of tests, including behavioral, radiologic, physiological, and serologic markers, that evaluate the brain's functional and structural integrity. Observations Prognostic markers, such as the neurologic examination, electroencephalography, and conventional computed tomography and magnetic resonance imaging (MRI), have been foundational in assessing a patient's current level of consciousness and capacity for recovery. Emerging techniques, such as functional MRI, diffusion MRI, and advanced forms of electroencephalography, provide new ways of evaluating the brain, leading to evolving schemes for characterizing neurologic function and novel methods for predicting recovery. Conclusions and Relevance Neuroprognostic markers are rapidly evolving as new ways of assessing the brain's structural and functional integrity after brain injury are discovered. Many of these techniques remain in development, and further research is needed to optimize their prognostic utility. However, even as such efforts are underway, a series of promising findings coupled with the imperfect predictive value of conventional prognostic markers and the high stakes of these assessments have prompted clinical guidelines to endorse emerging techniques for neuroprognostication. Thus, clinicians have been thrust into an uncertain predicament in which emerging techniques are not yet perfected but too promising to ignore. This review illustrates the current, and likely future, landscapes of prognostic markers. No matter how much prognostic markers evolve and improve, these assessments must be approached with humility and individualized to reflect each patient's values.
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Affiliation(s)
- David Fischer
- Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown
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7
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Abstract
Patients with disorders of consciousness who survive to discharge following severe acute brain injury may face profoundly complex medical, ethical, and psychosocial challenges during their courses of recovery and rehabilitation. Although issues encountered in caring for such patients during acute hospitalization have received substantial attention, ethical challenges that may arise in subacute and chronic phases have been underexplored. Shedding light on these issues, this article explores the landscape of normative issues in the course of treating and facilitating access to care for persons with disorders of consciousness during rehabilitation and examines potential implications for patients, clinicians, family members, and society.
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Affiliation(s)
- Michael J Young
- Department of Neurology, Massachusetts General Hospital, Center for Neurotechnology and Neurorecovery, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA.
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8
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Xu LB, Hampton S, Fischer D. Neuroimaging in Disorders of Consciousness and Recovery. Phys Med Rehabil Clin N Am 2024; 35:51-64. [PMID: 37993193 DOI: 10.1016/j.pmr.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
There is a clinical need for more accurate diagnosis and prognostication in patients with disorders of consciousness (DoC). There are several neuroimaging modalities that enable detailed, quantitative assessment of structural and functional brain injury, with demonstrated diagnostic and prognostic value. Additionally, longitudinal neuroimaging studies have hinted at quantifiable structural and functional neuroimaging biomarkers of recovery, with potential implications for the management of DoC.
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Affiliation(s)
- Linda B Xu
- Department of Neurology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Stephen Hampton
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 1800 Lombard Street, Philadelphia, PA 19146, USA
| | - David Fischer
- Department of Neurology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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9
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Young MJ, Kazazian K, Fischer D, Lissak IA, Bodien YG, Edlow BL. Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation. Neurocrit Care 2024:10.1007/s12028-023-01899-8. [PMID: 38243150 DOI: 10.1007/s12028-023-01899-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 01/21/2024]
Abstract
The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
| | - Karnig Kazazian
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Western Institute of Neuroscience, Western University, London, ON, Canada
| | - David Fischer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - India A Lissak
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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10
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Abstract
Neuroprognostication following acute brain injury (ABI) is a complex process that involves integrating vast amounts of information to predict a patient's likely trajectory of neurologic recovery. In this setting, critically evaluating salient ethical questions is imperative, and the implications often inform high-stakes conversations about the continuation, limitation, or withdrawal of life-sustaining therapy. While neuroprognostication is central to these clinical "life-or-death" decisions, the ethical underpinnings of neuroprognostication itself have been underexplored for patients with ABI. In this article, we discuss the ethical challenges of individualized neuroprognostication including parsing and communicating its inherent uncertainty to surrogate decision-makers. We also explore the population-based ethical considerations that arise in the context of heterogenous prognostication practices. Finally, we examine the emergence of artificial intelligence-aided neuroprognostication, proposing an ethical framework relevant to both modern and longstanding prognostic tools.
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Affiliation(s)
- India A Lissak
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Eric Rosenthal
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael J Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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11
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Steinberg A, Fischhoff B. Cognitive Biases and Shared Decision Making in Acute Brain Injury. Semin Neurol 2023; 43:735-743. [PMID: 37793424 DOI: 10.1055/s-0043-1775596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, Neurology, and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
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12
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Carlson JM, Lin DJ. Prognostication in Prolonged and Chronic Disorders of Consciousness. Semin Neurol 2023; 43:744-757. [PMID: 37758177 DOI: 10.1055/s-0043-1775792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Patients with prolonged disorders of consciousness (DOCs) longer than 28 days may continue to make significant gains and achieve functional recovery. Occasionally, this recovery trajectory may extend past 3 (for nontraumatic etiologies) and 12 months (for traumatic etiologies) into the chronic period. Prognosis is influenced by several factors including state of DOC, etiology, and demographics. There are several testing modalities that may aid prognostication under active investigation including electroencephalography, functional and anatomic magnetic resonance imaging, and event-related potentials. At this time, only one treatment (amantadine) has been routinely recommended to improve functional recovery in prolonged DOC. Given that some patients with prolonged or chronic DOC have the potential to recover both consciousness and functional status, it is important for neurologists experienced in prognostication to remain involved in their care.
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Affiliation(s)
- Julia M Carlson
- Division of Neurocritical Care, Department of Neurology, University of North Carolina Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David J Lin
- Center for Neurotechnology and Neurorecovery, Division of Neurocritical Care and Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Neurorestoration and Neurotechnology, Rehabilitation Research and Development Service, Department of Veterans Affairs, Providence, Rhode Island
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Miranda SP, Morris RS, Rabas M, Creutzfeldt CJ, Cooper Z. Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations. Neurocrit Care 2023; 39:284-293. [PMID: 37349599 DOI: 10.1007/s12028-023-01764-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/11/2023] [Indexed: 06/24/2023]
Abstract
Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, 15 South Tower, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Rachel S Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mackenzie Rabas
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Edlow BL, Fecchio M, Bodien YG, Comanducci A, Rosanova M, Casarotto S, Young MJ, Li J, Dougherty DD, Koch C, Tononi G, Massimini M, Boly M. Measuring Consciousness in the Intensive Care Unit. Neurocrit Care 2023; 38:584-590. [PMID: 37029315 DOI: 10.1007/s12028-023-01706-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/23/2023] [Indexed: 04/09/2023]
Abstract
Early reemergence of consciousness predicts long-term functional recovery for patients with severe brain injury. However, tools to reliably detect consciousness in the intensive care unit are lacking. Transcranial magnetic stimulation electroencephalography has the potential to detect consciousness in the intensive care unit, predict recovery, and prevent premature withdrawal of life-sustaining therapy.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.
| | - Matteo Fecchio
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Angela Comanducci
- IRCCS Fondazione Don Carlo Gnocchi Onlus, Milan, Italy
- Università Campus Bio-Medico di Roma, Rome, Italy
| | - Mario Rosanova
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Silvia Casarotto
- IRCCS Fondazione Don Carlo Gnocchi Onlus, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jian Li
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Darin D Dougherty
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Christof Koch
- MindScope Program, Allen Institute, Seattle, WA, USA
- Tiny Blue Dot Foundation, Santa Monica, CA, USA
| | - Giulio Tononi
- Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA
| | - Marcello Massimini
- IRCCS Fondazione Don Carlo Gnocchi Onlus, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Melanie Boly
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, USA
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15
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Mainali S. Neurologic Complications of Cardiac and Pulmonary Disease. Continuum (Minneap Minn) 2023; 29:684-707. [PMID: 37341327 DOI: 10.1212/con.0000000000001284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE The heart and lungs work as a functional unit through a complex interplay. The cardiorespiratory system is responsible for the delivery of oxygen and energy substrates to the brain. Therefore, diseases of the heart and lungs can lead to various neurologic illnesses. This article reviews various cardiac and pulmonary pathologies that can lead to neurologic injury and discusses the relevant pathophysiologic mechanisms. LATEST DEVELOPMENTS We have lived through unprecedented times over the past 3 years with the emergence and rapid spread of the COVID-19 pandemic. Given the effects of COVID-19 on the lungs and heart, an increased incidence of hypoxic-ischemic brain injury and stroke associated with cardiorespiratory pathologies has been observed. Newer evidence has questioned the benefit of induced hypothermia in patients with out-of-hospital cardiac arrest. Further, global collaborative initiatives such as the Curing Coma Campaign are underway with the goal of improving the care of patients with coma and disorders of consciousness, including those resulting from cardiac and pulmonary pathologies. ESSENTIAL POINTS The neurologic complications of cardiorespiratory disorders are common and present in various forms such as stroke or hypoxic and anoxic injury related to cardiac or respiratory failure. With the emergence of the COVID-19 pandemic, neurologic complications have increased in recent years. Given the intimate and interdependent dynamics of the heart, lungs, and brain, it is crucial for neurologists to be aware of the interplay between these organs.
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Friedman ML, Beardsley AL. Decision-Making and Ethical Considerations of Tracheostomy and Chronic Mechanical Ventilation in Children with Acute Neurological Injury. Semin Pediatr Neurol 2023; 45:101032. [PMID: 37003626 DOI: 10.1016/j.spen.2023.101032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/18/2023] [Accepted: 01/31/2023] [Indexed: 02/12/2023]
Abstract
The decisions around whether or not to provide tracheostomy and chronic mechanical ventilation to children with acute neurologic injury are difficult for medical providers and surrogate decision makers. Consideration of the 4 primary principles of medical ethics-autonomy, beneficence, non-maleficence, and justice-can provide a framework from which constructive discussions can form. Determination of the goals of care is a good first step in navigating these complex decisions. A shared decision model should be used, including education of decision-makers by medical providers and appropriate recommendations based on the stated goals of care. In this paper, 2 illustrative cases are discussed highlighting the utility of this decision-making framework.
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Affiliation(s)
- Matthew L Friedman
- Division of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN.
| | - Andrew L Beardsley
- Division of Pediatric Critical Care, Peyton Manning Children's Hospital, Indianapolis, IN
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17
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Xiong Q, Wang Y, Wang Z, Tang Y, Huang L, Kang J, Feng Z. Relationship between consciousness level and perfusion computed tomography in patients with prolonged disorders of consciousness. Aging (Albany NY) 2022; 14:9668-9678. [PMID: 36470667 PMCID: PMC9792208 DOI: 10.18632/aging.204417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/23/2022] [Indexed: 12/09/2022]
Abstract
PURPOSE We assessed the relationship between consciousness level and values of cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) obtained by whole-brain perfusion computed tomography (pCT) in patients with prolonged disorders of consciousness (pDOC). METHODS This study included 29 patients in vegetative state (VS), 34 with minimally consciousness state minus (MCS-), and 13 with minimally consciousness state plus (MCS+). All patients were evaluated using the Coma Recovery Scale-Revised (CRS-R), the Glasgow Coma Scale (GCS), and the Full Outline of UnResponsiveness (FOUR). The values of CBF, CBV, MTT, and TTP were obtained from patients who underwent pCT. Differences in CBF, CBV, MTT, and TTP were compared between the three types of pDOC. Correlations between the CRS-R, GCS, and FOUR scores and the pCT results were analyzed. RESULTS Among the three groups, patients in VS showed a significantly decreased CBF in the bilateral frontal lobe, thalamus, temporal lobe, occipital lobe, brainstem, and damaged part. CBV was significantly reduced in patients with VS in the bilateral frontal lobe, thalamus, temporal lobe, brainstem, and damaged part. The total CRS-R, GCS, and FOUR scores were positively correlated with CBF, CBV, and TTP in almost all regions of interest. CONCLUSION Reductions in CBF and CBV calculated with pCT are associated with impaired consciousness and perfusion CT could be a promising tool in evaluating the conscious level in patients with pDOC.
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Affiliation(s)
- Qi Xiong
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Yong Wang
- Department of Medical Oncology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Ziwen Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Yunliang Tang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Lianghua Huang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Junwei Kang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Zhen Feng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
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18
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Yechoor N, Rosand J. Helping Families With Fateful Decisions. Neurology 2022; 99:593-594. [PMID: 35853749 DOI: 10.1212/wnl.0000000000201145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/06/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Nirupama Yechoor
- From the Henry and Allison McCance Center for Brain Health (N.Y., J.R.), Massachusetts General Hospital, Boston; Division of Neurocritical Care (N.Y., J.R.), Massachusetts General Hospital, Boston; Department of Neurology (N.Y., J.R.), Harvard Medical School, Boston; and Program in Medical and Population Genetics (J.R.), the Broad Institute, Cambridge, MA
| | - Jonathan Rosand
- From the Henry and Allison McCance Center for Brain Health (N.Y., J.R.), Massachusetts General Hospital, Boston; Division of Neurocritical Care (N.Y., J.R.), Massachusetts General Hospital, Boston; Department of Neurology (N.Y., J.R.), Harvard Medical School, Boston; and Program in Medical and Population Genetics (J.R.), the Broad Institute, Cambridge, MA.
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19
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Fusco A, Galluccio C, Castelli L, Pazzaglia C, Pastorino R, Pires Marafon D, Bernabei R, Giovannini S, Padua L. Severe Acquired Brain Injury: Prognostic Factors of Discharge Outcome in Older Adults. Brain Sci 2022; 12:brainsci12091232. [PMID: 36138968 PMCID: PMC9496921 DOI: 10.3390/brainsci12091232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022] Open
Abstract
Severe Acquired Brain Injury (sABI) is a leading cause of disability and requires intensive rehabilitation treatment. Discharge from the rehabilitation ward is a key moment in patient management. Delays in patient discharge can adversely affect hospital productivity and increase healthcare costs. The discharge should be structured from the hospital admission toward the most appropriate environment. The purpose of our study is to investigate early predictors of outcome for discharge in older adults with sABI. A retrospective study was performed on 22 patients who were admitted to an intensive neurorehabilitation unit between June 2019 and December 2021. Patients were divided into two outcome categories, good outcome (GO) or poor outcome (PO), based on discharge destination, and the possible prognostic factors were analyzed at one and two months after admission. Among the factors analyzed, changes in the Disability Rating Scale (DRS) and Level of Cognitive Functioning (LCF) at the first and second month of hospitalization were predictive of GO at discharge (DRS, p = 0.025; LCF, p = 0.011). The presence of percutaneous endoscopic gastrostomy at two months after admission was also significantly associated with PO (p = 0.038). High Body Mass Index (BMI) and the presence of sepsis at one month after admission were possible predictors of PO (BMI p = 0.048; sepsis p = 0.014). An analysis of dynamic predictors could be useful to guarantee an early evaluation of hospital discharge in frail patients with sABI.
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Affiliation(s)
- Augusto Fusco
- UOC Neuroriabilitazione ad Alta Intensità, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Caterina Galluccio
- UOC Neuroriabilitazione ad Alta Intensità, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Geriatrics and Orthopaedics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Letizia Castelli
- UOC Neuroriabilitazione ad Alta Intensità, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Costanza Pazzaglia
- UOC Neuroriabilitazione ad Alta Intensità, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Roberta Pastorino
- Department of Woman and Child Health and Public Health—Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Denise Pires Marafon
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Roberto Bernabei
- Department of Geriatrics and Orthopaedics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Silvia Giovannini
- Department of Geriatrics and Orthopaedics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- UOS Neuroriabilitazione Post-acuzie, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-06-3015-4382
| | - Luca Padua
- UOC Neuroriabilitazione ad Alta Intensità, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Geriatrics and Orthopaedics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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