1
|
Mansour A, Powla PP, Alvarado-Dyer R, Fakhri F, Das P, Horowitz P, Goldenberg FD, Lazaridis C. Comparative Analysis of Clinical Severity and Outcomes in Penetrating Versus Blunt Traumatic Brain Injury Propensity Matched Cohorts. Neurotrauma Rep 2024; 5:348-358. [PMID: 38595793 PMCID: PMC11002325 DOI: 10.1089/neur.2024.0009] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Traumatic brain injury (TBI) is a global health challenge; however, penetrating brain injury (PBI) remains under-represented in evidence-based knowledge and research efforts. This study utilized data from the Trauma Quality Improvement Program (TQIP) of the National Trauma Data Bank (NTDB) to investigate outcomes of PBI as compared with clinical-severity-matched non-penetrating or blunt TBI. A total of 1765 patients with PBI were 1:1 propensity score-matched for clinical severity with blunt TBI patients. The intent of PBI was self-inflicted in 34.1% of the cases, and the mechanism was firearm-inflicted in 89.1%. Mortality was found to be significantly more common in PBI than in the severity- matched TBI cohort (33.9% vs. 14.3 %, p < 0.001) as was unfavorable outcome. Mortality was mediated by withdrawal of life-sustaining therapies (WOLST) 30% of the time, and WOLST occurred earlier (median 3 days vs. 6 days, p < 0.001) in PBI. Increased rate of mortality was observed with a Glasgow Coma Scale (GCS) of <11 in PBI as compared with <7 in blunt TBI. In conclusion, PBI patients exhibited higher mortality rates and unfavorable outcomes; one third of excess mortality was mediated by WOLST. The study also brings into question the applicability of the conventional TBI classification, based on GCS, in PBI. We emphasize the need to address the observed disparities and better understand the distinctive characteristics and mechanisms underlying PBI outcomes to improve patient care and reduce mortality.
Collapse
Affiliation(s)
- Ali Mansour
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago, Illinois, USA
- Department of Neurological Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Plamena P. Powla
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Ronald Alvarado-Dyer
- Department of Neurology, Neurosciences Intensive Care Unit, OU Health University of Oklahoma Medical Center, Oklahoma City, Oklahoma, USA
| | - Farima Fakhri
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Paramita Das
- Department of Neurological Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Peleg Horowitz
- Department of Neurological Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Fernando D. Goldenberg
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago, Illinois, USA
- Department of Neurological Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Christos Lazaridis
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago, Illinois, USA
- Department of Neurological Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| |
Collapse
|
2
|
Morsi RZ, Baskaran A, Thind S, Carrión-Penagos J, Desai H, Kothari SA, Mirza M, Lazaridis C, Goldenberg F, Hurley MC, Mendelson SJ, Prabhakaran S, Zakrison T, Mansour A, Kass-Hout T. Endovascular Embolization of Traumatic Vessel Injury Using N-butyl Cyanoacrylate: A Case Series. Indian J Otolaryngol Head Neck Surg 2024; 76:1554-1562. [PMID: 38566650 PMCID: PMC10982176 DOI: 10.1007/s12070-023-04357-1] [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] [Received: 10/08/2023] [Accepted: 11/12/2023] [Indexed: 04/04/2024] Open
Abstract
There is limited evidence of N-butyl cyanoacrylate (n-BCA) use in endovascular embolization of traumatic face and neck vessel injuries. We investigated the safety and effectiveness of n-BCA for this purpose. We retrospectively analyzed consecutive patients presenting to a Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18 years old with any vessel injury in the face and neck circulation requiring n-BCA embolization. The primary endpoint was n-BCA effectiveness defined as immediate control of active bleeding post-embolization. In total, 13 patients met the inclusion criteria. The median decade of life was 3 (IQR 3 - 5) with a male predominance (n = 11, 84.6%). Median Glasgow Coma Scale score on presentation was 15 (IQR 3-15). Eleven patients suffered gunshot wound injuries; two patients suffered blunt injuries. Injured vessels included facial artery (n = 6, 46.2%), buccal branch artery (n = 3, 23.1%), internal maxillary (n = 5, 38.5%), cervical internal carotid artery (n = 1, 7.7%), and vertebral artery (n = 1, 7.7%). All patients were treated with 1:2 n-BCA to ethiodol mixture with immediate extravasation control. No bleeding recurrence or need for retreatment occurred. One patient died in-hospital (7.7%). Patients were discharged to home (n = 8, 61.5%), day rehabilitation (n = 1, 7.7%), or acute rehabilitation (n = 3, 23.1%). One patient developed a right posterior cerebral artery infarct with hemorrhagic transformation. To our knowledge, this is the first study demonstrating the safety and effectiveness of n-BCA liquid embolism in traumatic vessel injuries, especially penetrating gunshot wounds.
Collapse
Affiliation(s)
- Rami Z. Morsi
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | - Archit Baskaran
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | - Sonam Thind
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | - Julián Carrión-Penagos
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | - Harsh Desai
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | - Sachin A. Kothari
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | - Mahmood Mirza
- Cerenovus (Johnson & Johnson), Galway Neuro Technology Center, Galway, Ireland
| | - Christos Lazaridis
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | - Fernando Goldenberg
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | | | - Scott J. Mendelson
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | - Tanya Zakrison
- Department of Surgery, University of Chicago, Chicago, IL USA
| | - Ali Mansour
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, 5841 S Maryland Ave., MC 2030, Chicago, IL USA
| |
Collapse
|
3
|
Mansour A, Powla PP, Fakhri F, Alvarado-Dyer R, Das P, Horowitz P, Goldenberg FD, Lazaridis C. Comparative Effectiveness of Early Neurosurgical Intervention in Civilian Penetrating Brain Injury Management. Neurosurgery 2024; 94:470-477. [PMID: 37847039 DOI: 10.1227/neu.0000000000002725] [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] [Received: 06/02/2023] [Accepted: 08/25/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To compare the outcomes of early vs no-neurosurgical intervention in civilians with penetrating brain injury (PBI). METHODS We collected data from the National Trauma Data Bank for PBI between 2017 and 2019. A total of 10 607 cases were identified; 1276 cases met the following criteria: age 16-60 years, an intensive care unit (ICU) length of stay (LOS) of >2 days, a Glasgow Coma Scale of 3-12, and at least one reactive pupil on presentation. Patients with withdrawal of life-sustaining treatments within 72 hours were excluded, leaving 1231 patients for analysis. Neurosurgical intervention was defined as an open-approach cranial procedure involving release, drainage, or extirpation of brain matter performed within 24 hours. Outcomes of interest were mortality, withdrawal of life-sustaining treatments, ICU LOS, and dispositional outcome. RESULTS The target population was 1231 patients (84.4% male; median [IQR] age, 29 [18] years); 267 (21.7%) died, and 364 (29.6%) had a neurosurgical intervention within the first 24 hours. 1:1 matching yielded 704 patients (352 in each arm). In the matched cohort (mortality 22.6%), 64 patients who received surgery (18.2%) died compared with 95 (27%) in the nonsurgical group. Survival was more likely in the surgical group (odds ratio [OR] 1.66, CI 1.16-2.38, P < .01; number needed to treat 11). Dispositional outcome was not different. Overlap propensity score-weighted analysis (1231 patients) resulted in higher odds of survival in the surgical group (OR 1.8, CI 1.16-2.80, P < .01). The E-value for the OR calculated from the matched data set was 2.83. Early neurosurgical intervention was associated with longer ICU LOS (median 12 days [7.0, 19.0 IQR] vs 8 days [4.0, 15.0 IQR], P < .05). CONCLUSION Management including early neurosurgical intervention is associated with decreased mortality and increased ICU LOS in matched cohorts of PBI.
Collapse
Affiliation(s)
- Ali Mansour
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
- Department of Neurosurgery, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Plamena P Powla
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Farima Fakhri
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Ronald Alvarado-Dyer
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Paramita Das
- Department of Neurosurgery, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Peleg Horowitz
- Department of Neurosurgery, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Fernando D Goldenberg
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
- Department of Neurosurgery, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Christos Lazaridis
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
- Department of Neurosurgery, University of Chicago Medical Center, Chicago , Illinois , USA
| |
Collapse
|
4
|
Kalkach Aparicio M, Lazaridis C. Conceptualizing Consciousness: a Change in Perspective: The Elephant Still Surprises Those only Touching Its Trunk. Phys Med Rehabil Clin N Am 2024; 35:1-13. [PMID: 37993181 DOI: 10.1016/j.pmr.2023.06.021] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Providers of patients with disorders of consciousness (DoC) face clinical and ethical challenges that could be lessened by becoming acquainted with the subjective and objective aspects of consciousness. A first step to improving DoC taxonomies, management, and outcomes might be to recognize the shortcomings of the medical concept of consciousness and to improve the terminology used for the clinical parameters assessed. The authors critically review the medical perspective of consciousness represented by three sub-concepts that do not necessarily correlate with one another and discuss how none of them reflects fully the personal subjective nature of consciousness.
Collapse
Affiliation(s)
- Mariel Kalkach Aparicio
- Department of Neurology, University of Wisconsin, 1685 Highland Avenue, 7th Floor, Madison, WI 53705-2281, USA; Centro Anahuac de Desarrollo Estrategico en Bioetica (CADEBI), Universidad Anahuac Mexico, Edo. Mex. MEX; UNESCO Chair of Bioethics and Human Rights, Rome, ITA.
| | - Christos Lazaridis
- Department of Neurology, The University of Chicago, 5841 South Maryland Avenue, MC 2030, Chicago, IL 60637, USA
| |
Collapse
|
5
|
Tangonan R, Lazaridis C. Evaluation and Management of Disorders of Consciousness in the Acute Care Setting. Phys Med Rehabil Clin N Am 2024; 35:79-92. [PMID: 37993195 DOI: 10.1016/j.pmr.2023.06.013] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Acute disorders of consciousness (DOC) are impairments in arousal and awareness that occur within 28 days of an initial injury and can result from a variety of insults. These states range from coma, unresponsive wakefulness, covert consciousness, minimal consciousness, to confusional state. It is important to perform thorough, serial examinations with particular emphasis on the level of consciousness, brainstem reflexes, and motor responses. Evaluation of acute DOC includes laboratory tests, imaging, and electrophysiology testing. Prognostication in the acute phase of DOC must be done cautiously, using open, frequent communication with families, and by acknowledging significant multidimensional uncertainty.
Collapse
Affiliation(s)
- Ruth Tangonan
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| |
Collapse
|
6
|
Lazaridis C, Wolf M, Roth WH, Fan T, Mansour A, Goldenberg FD. Apnea Test: The Family in the Room. Neurocrit Care 2023:10.1007/s12028-023-01906-y. [PMID: 38158482 DOI: 10.1007/s12028-023-01906-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA.
| | - Mary Wolf
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - William H Roth
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Tracey Fan
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Ali Mansour
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Fernando D Goldenberg
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| |
Collapse
|
7
|
Lazaridis C. Resuscitation for Donation After Brain Death: Respecting Autonomy and Maximizing Utility. Crit Care Med 2023:00003246-990000000-00245. [PMID: 38059731 DOI: 10.1097/ccm.0000000000006139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Affiliation(s)
- Christos Lazaridis
- Department of Neurology, University of Chicago, Chicago, IL
- Department of Neurosurgery, University of Chicago, Chicago, IL
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
| |
Collapse
|
8
|
Foreman B, Kapinos G, Wainwright MS, Ngwenya LB, O'Phelan KH, LaRovere KL, Kirschen MP, Appavu B, Lazaridis C, Alkhachroum A, Maciel CB, Amorim E, Chang JJ, Gilmore EJ, Rosenthal ES, Park S. Practice Standards for the Use of Multimodality Neuromonitoring: A Delphi Consensus Process. Crit Care Med 2023; 51:1740-1753. [PMID: 37607072 PMCID: PMC11036878 DOI: 10.1097/ccm.0000000000006016] [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: 08/24/2023]
Abstract
OBJECTIVES To address areas in which there is no consensus for the technologies, effort, and training necessary to integrate and interpret information from multimodality neuromonitoring (MNM). DESIGN A three-round Delphi consensus process. SETTING Electronic surveys and virtual meeting. SUBJECTS Participants with broad MNM expertise from adult and pediatric intensive care backgrounds. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two rounds of surveys were completed followed by a virtual meeting to resolve areas without consensus and a final survey to conclude the Delphi process. With 35 participants consensus was achieved on 49% statements concerning MNM. Neurologic impairment and the potential for MNM to guide management were important clinical considerations. Experts reached consensus for the use of MNM-both invasive and noninvasive-for patients in coma with traumatic brain injury, aneurysmal subarachnoid hemorrhage, and intracranial hemorrhage. There was consensus that effort to integrate and interpret MNM requires time independent of daily clinical duties, along with specific skills and expertise. Consensus was reached that training and educational platforms are necessary to develop this expertise and to provide clinical correlation. CONCLUSIONS We provide expert consensus in the clinical considerations, minimum necessary technologies, implementation, and training/education to provide practice standards for the use of MNM to individualize clinical care.
Collapse
Affiliation(s)
- Brandon Foreman
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | - Gregory Kapinos
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mark S Wainwright
- Division of Pediatric Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Laura B Ngwenya
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH
| | | | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Matthew P Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brian Appavu
- Departments of Child Health and Neurology, Phoenix Children's, University of Arizona College of Medicine-Phoenix, Phoenix, AZ
| | - Christos Lazaridis
- Departments of Neurology and Neurosurgery, University of Chicago, Chicago, IL
| | | | - Carolina B Maciel
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Pediatric Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH
- Department of Neurology, University of Miami, Miami, FL
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Departments of Child Health and Neurology, Phoenix Children's, University of Arizona College of Medicine-Phoenix, Phoenix, AZ
- Departments of Neurology and Neurosurgery, University of Chicago, Chicago, IL
- Departments of Neurology and Neurosurgery, University of Florida, Tampa, FL
- Department of Neurology, University of Utah, Salt Lake City, UT
- Department of Neurology, Yale University, New Haven, CT
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
- Department of Critical Care and Georgetown University, Department of Neurology, MedStar Washington Hospital Center, Washington, DC
- Department of Neurology, Massachusetts General Hospital, Boston, MA
- Departments of Neurology and Biomedical Informatics, Columbia University, New York, NY
| | - Edilberto Amorim
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Jason J Chang
- Department of Critical Care and Georgetown University, Department of Neurology, MedStar Washington Hospital Center, Washington, DC
| | | | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Soojin Park
- Departments of Neurology and Biomedical Informatics, Columbia University, New York, NY
| |
Collapse
|
9
|
Lazaridis C. Cerebral blood flow after thoracoabdominal normothermic regional perfusion: Fundamental yet underexplored. J Heart Lung Transplant 2023; 42:1764-1765. [PMID: 37683893 DOI: 10.1016/j.healun.2023.09.002] [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: 08/28/2023] [Accepted: 09/02/2023] [Indexed: 09/10/2023] Open
Affiliation(s)
- Christos Lazaridis
- Department of Neurology, University of Chicago, Chicago, Illinois; Department of Neurosurgery, University of Chicago, Chicago, Illinois; MacLean Center for Clinical Medical Ethics at the University of Chicago, Chicago, Illinois.
| |
Collapse
|
10
|
Ciarrocchi N, Pose F, Videla CG, Del Carmen García M, Goldenberg FD, Lazaridis C, Issa NP, Redelico FO, Mansour A. Novel EEG Metric Correlates with Intracranial Pressure in an Animal Model. Neurocrit Care 2023:10.1007/s12028-023-01848-5. [PMID: 37940837 DOI: 10.1007/s12028-023-01848-5] [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] [Received: 05/03/2023] [Accepted: 08/23/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Intracranial pressure (ICP) can be continuously and reliably measured using invasive monitoring through an external ventricular catheter or an intraparenchymal probe. We explore electroencephalography (EEG) to identify a reliable real-time noninvasive ICP correlate. METHODS Using a previously described porcine model of intracranial hypertension, we examined the cross correlation between ICP time series and the slope of the EEG power spectral density as described by ϕ. We calculated ϕ as tan-1 (slope of power spectral density) and normalized it by π, where slope is that of the power-law fit (log frequency vs. log power) to the power spectral density of the EEG signal. Additionally, we explored the relationship between the ϕ time series and cerebral perfusion pressure. A total of 11 intracranial hypertension episodes across three different animals were studied. RESULTS The mean correlation between ϕ angle and ICP was - 0.85 (0.15); the mean correlation with cerebral perfusion pressure was 0.92 (0.02). Significant correlation occurred at zero lag. In the absence of intracranial hypertension, the absolute value of the ϕ angle was greater than 0.9 (mean 0.936 radians). However, during extreme intracranial hypertension causing cerebral circulatory arrest, the ϕ angle is on average below 0.9 radians (mean 0.855 radians). CONCLUSIONS EEG ϕ angle is a promising real-time noninvasive measure of ICP/cerebral perfusion using surface electroencephalography.
Collapse
Affiliation(s)
- Nicolás Ciarrocchi
- Servicio de Terapia Intensiva de Adultos, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190 - (C1199ABB), Ciudad Autónoma de Buenos Aires, Argentina
| | - Fernando Pose
- Instituto de Medicina Traslacional e Ingeniería Biomédica, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires and, Consejo Nacional de Investigaciones Científicas y Técnicas, Perón 4190, Ciudad Autónoma de Buenos Aires, Argentina
| | - Carlos Gustavo Videla
- Instituto de Medicina Traslacional e Ingeniería Biomédica, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires and, Consejo Nacional de Investigaciones Científicas y Técnicas, Perón 4190, Ciudad Autónoma de Buenos Aires, Argentina
| | - María Del Carmen García
- Servicio de Neurología Adultos, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, Ciudad Autónoma de Buenos Aires, Argentina
| | - Fernando D Goldenberg
- Neurocritical Care Section, Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Christos Lazaridis
- Neurocritical Care Section, Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Naoum P Issa
- Epilepsy Section, Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Francisco O Redelico
- Instituto de Medicina Traslacional e Ingeniería Biomédica, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires and, Consejo Nacional de Investigaciones Científicas y Técnicas, Perón 4190, Ciudad Autónoma de Buenos Aires, Argentina.
- Departamento de Ciencia y Tecnología, Universidad Nacional de Quilmes, Roque Sáenz Peña 352 - (B1876BXD), Bernal, Buenos Aires, Argentina.
| | - Ali Mansour
- Neurocritical Care Section, Department of Neurology, University of Chicago, Chicago, IL, USA.
| |
Collapse
|
11
|
Lazaridis C, Das P. Penetrating Firearm-Inflicted Injury-The Neglected Traumatic Brain Injury. JAMA Neurol 2023; 80:1013-1014. [PMID: 37669024 DOI: 10.1001/jamaneurol.2023.3030] [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: 09/06/2023]
Abstract
This Viewpoint discusses penetrating firearm-inflicted brain injury and the current collaborative efforts to perform more penetrating brain injury–specific randomized clinical trials and comparative effectiveness research to identify effective management guidelines.
Collapse
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois
- Department of Neurosurgery, University of Chicago Medical Center, Chicago, Illinois
| | - Paramita Das
- Department of Neurosurgery, University of Chicago Medical Center, Chicago, Illinois
| |
Collapse
|
12
|
Lazaridis C, Foreman B. Management Strategies Based on Multi-Modality Neuromonitoring in Severe Traumatic Brain Injury. Neurotherapeutics 2023; 20:1457-1471. [PMID: 37491682 PMCID: PMC10684466 DOI: 10.1007/s13311-023-01411-2] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 07/27/2023] Open
Abstract
Secondary brain injury after neurotrauma is comprised of a host of distinct, potentially concurrent and interacting mechanisms that may exacerbate primary brain insult. Multimodality neuromonitoring is a method of measuring multiple aspects of the brain in order to understand the signatures of these different pathomechanisms and to detect, treat, or prevent potentially reversible secondary brain injuries. The most studied invasive parameters include intracranial pressure (ICP), cerebral perfusion pressure (CPP), autoregulatory indices, brain tissue partial oxygen tension, and tissue energy and metabolism measures such as the lactate pyruvate ratio. Understanding the local metabolic state of brain tissue in order to infer pathology and develop appropriate management strategies is an area of active investigation. Several clinical trials are underway to define the role of brain tissue oxygenation monitoring and electrocorticography in conjunction with other multimodal neuromonitoring information, including ICP and CPP monitoring. Identifying an optimal CPP to guide individualized management of blood pressure and ICP has been shown to be feasible, but definitive clinical trial evidence is still needed. Future work is still needed to define and clinically correlate patterns that emerge from integrated measurements of metabolism, pressure, flow, oxygenation, and electrophysiology. Pathophysiologic targets and precise critical care management strategies to address their underlying causes promise to mitigate secondary injuries and hold the potential to improve patient outcome. Advancements in clinical trial design are poised to establish new standards for the use of multimodality neuromonitoring to guide individualized clinical care.
Collapse
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA.
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
13
|
Lazaridis C. Informed Consent and Decision-Making for Patients with Acquired Cognitive Impairment. Neurol Clin 2023; 41:433-442. [PMID: 37407097 DOI: 10.1016/j.ncl.2023.03.001] [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: 07/07/2023]
Abstract
Informed consent (IC) is an ethical and legal requirement grounded in the principle of autonomy. Cognitive impairment may often interfere with decision-making capacity necessitating alternative models of ethically sound deliberation. In cases where the patient lacks decision-making capacity, one must determine the appropriate decision-maker and the criteria used in making a medical decision appropriate for the patient. In this article, I critically discuss the traditional approaches of IC, advance directives, substituted judgment, and best interests. A further suggestion is that thinking about sufficient reasons for or against a course of action is a conceptual enrichment in addition to the concepts of interests and well-being. Finally, I propose another model of collective consensus-seeking decision-making.
Collapse
Affiliation(s)
- Christos Lazaridis
- Department of Neurology, University of Chicago, IL, USA; Department of Neurosurgery, University of Chicago, IL, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, IL.
| |
Collapse
|
14
|
Lazaridis C. Permanent Cerebral Circulatory Arrest Is Necessary and Sufficient for Normothermic Regional Perfusion. Crit Care Med 2023; 51:e95-e96. [PMID: 36928017 DOI: 10.1097/ccm.0000000000005772] [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] [Indexed: 03/18/2023]
Affiliation(s)
- Christos Lazaridis
- Departments of Neurology, Neurosurgery, and the MacLean Center for Clinical Medical Ethics, University of Chicago Medical Center, Chicago, IL
| |
Collapse
|
15
|
Mansour A, Rowell S, Powla PP, Horowitz P, Goldenberg FD, Lazaridis C. Comparative Effectiveness of Intracranial Pressure Monitoring vs No Monitoring in Severe Penetrating Brain Injury Management. JAMA Netw Open 2023; 6:e231077. [PMID: 36961466 DOI: 10.1001/jamanetworkopen.2023.1077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
Importance Civilian penetrating brain injury (PBI) is associated with high mortality. However, scant literature is available to guide neurocritical care monitoring and management of PBI. Objective To examine the association of intracranial pressure (ICP) monitoring with mortality, intensive care unit (ICU) length of stay (LOS), and dispositional outcomes in patients with severe PBI. Design, Setting, and Participants This comparative effectiveness research study analyzed data from the Trauma Quality Improvement Program of the National Trauma Data Bank in the US from January 1, 2017, to December 31, 2019. Patients with PBI were identified, and those aged 16 and 60 years who met these inclusion criteria were included: ICU LOS of more than 2 days, Glasgow Coma Scale (GCS) score lower than 9 on arrival and at 24 hours, and Abbreviated Injury Scale score of 3 to 5 for the head region and lower than 3 for other body regions. Patients with bilaterally fixed pupils or incomplete data were excluded. A 1:1 propensity score (PS) matching was used to create a subgroup of patients. Patients were divided into 2 groups: with vs without ICP monitoring. Data analysis was conducted between September and December 2022. Exposures Intracranial pressure monitoring vs no monitoring. Main Outcomes and Measures Outcomes were mortality, rate of withdrawal, ICU LOS, and dispositional outcome. Measures were age, initial systolic blood pressure, initial oxygen saturation level on a pulse oximeter, first-recorded GCS score, GCS score at 24 hours, Abbreviated Injury Scale score, midline shift, and pupillary reactivity. Results A total of 596 patients (505 males [84.7%]; mean [SD] age, 32.2 [12.3] years) were included, among whom 220 (36.9%) died and 288 (48.3%) had ICP monitoring. The PS matching yielded 466 patients (233 in each group with vs without ICP monitoring). Overall mortality was 35.8%; 72 patients with ICP monitoring (30.9%) died compared with 95 patients (40.8%) without ICP monitoring . Patients with ICP monitoring were more likely to survive (odds ratio [OR], 1.54; 95% CI, 1.05-2.25; P = .03; number needed to treat, 10). No difference in favorable discharge disposition was observed. The PS-weighted analysis included all 596 patients and found that patients with ICP monitoring were more likely to survive than those without (OR, 1.40; 95% CI, 1.10-1.78; P = .005). The E-value for the OR calculated from the PS-matched data set was 1.79. In addition, ICP monitoring vs no monitoring was associated with an increase in median (IQR) ICU LOS (15.0 [8.0-21.0] days vs 7.0 [4.0-12.0] days; P < .001). Conclusions and Relevance In this comparative effectiveness research study, PBI management guided by ICP monitoring was associated with decreased mortality and increased ICU LOS, challenging the notion of universally poor outcomes after civilian PBI. Randomized clinical trials that evaluate the efficacy of ICP monitoring in PBI are warranted.
Collapse
Affiliation(s)
- Ali Mansour
- Division of Neurocritical Care, Department of Neurology, The University of Chicago Medical Center, Chicago, Illinois
- Department of Neurosurgery, The University of Chicago Medical Center, Chicago, Illinois
| | - Susan Rowell
- Division of Trauma and Acute Care Surgery, Department of Surgery, The University of Chicago Medical Center, Chicago, Illinois
| | - Plamena P Powla
- Division of Neurocritical Care, Department of Neurology, The University of Chicago Medical Center, Chicago, Illinois
| | - Peleg Horowitz
- Department of Neurosurgery, The University of Chicago Medical Center, Chicago, Illinois
| | - Fernando D Goldenberg
- Division of Neurocritical Care, Department of Neurology, The University of Chicago Medical Center, Chicago, Illinois
- Department of Neurosurgery, The University of Chicago Medical Center, Chicago, Illinois
| | - Christos Lazaridis
- Division of Neurocritical Care, Department of Neurology, The University of Chicago Medical Center, Chicago, Illinois
- Department of Neurosurgery, The University of Chicago Medical Center, Chicago, Illinois
| |
Collapse
|
16
|
Abstract
BACKGROUND There is lack of consensus in the bioethics literature regarding the use of cardiopulmonary resuscitation (CPR) for organ-preserving purposes. In this study, we assessed the perspectives of clinicians in critical care settings to better inform donor management policy and practice. METHODS An online anonymous survey of members of the Society of Critical Care Medicine that presented various scenarios about CPR for organ preservation. RESULTS The email was sent to 10,340 members. It was opened by 5,416 (52%) of members and 405 members (4%) completed the survey with few missing data. A majority of respondents (81%) answered that donation status should not influence whether CPR is performed on an imminently dying patient. There was very strong agreement (>85%) that 1) CPR should be performed on a registered donor who experiences a cardiac arrest with an unknown code status before death by neurological criteria (DNC) and 2) CPR should be performed if the patient is not a registered donor and experiences cardiac arrest but the surrogate/power of attorney (POA) has not yet been approached regarding code status and donation. When a registered donor with a DNR order experiences cardiac arrest before DNC, 98% of respondents would not perform CPR. However, after DNC, respondents were evenly divided on whether they would (49%) or would not (51%) perform CPR on a registered donor with an undocumented code status. When asked whether consent should be required for CPR for organ-preserving purposes, 39% answered "Yes" when a patient arrests before DNC and 48% answered "Yes" when a patient arrests after DNC (P = 0.2). CONCLUSIONS The majority of respondents did not consider donor status relevant to CPR decisions before DNC, and virtually all would respect a DNR order in a registered donor before DNC. Respondents were divided about the need for an affirmative consent for CPR for organ-preserving purposes both before and after DNC.
Collapse
Affiliation(s)
- Colin Eversmann
- The MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - Ayush Shah
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Christos Lazaridis
- Departments of Neurology and Neurosurgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Lainie F Ross
- Departments of Pediatrics, Medicine, Surgery and the College, University of Chicago, Chicago, IL, USA
| |
Collapse
|
17
|
Lazaridis C. Cerebral Circulatory Arrest and the Dead Donor Rule. Am J Bioeth 2023; 23:43-45. [PMID: 36681913 DOI: 10.1080/15265161.2022.2159572] [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] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
|
18
|
Alvarado-Dyer R, Aguilera S, Chesnut RM, Videtta W, Fischer D, Jibaja M, Godoy DA, Garcia RM, Goldenberg FD, Lazaridis C. Managing Severe Traumatic Brain Injury Across Resource Settings: Latin American Perspectives. Neurocrit Care 2023; 38:229-234. [PMID: 36635495 PMCID: PMC9836742 DOI: 10.1007/s12028-022-01670-5] [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] [Received: 10/19/2022] [Accepted: 12/19/2022] [Indexed: 01/14/2023]
Abstract
Severe traumatic brain injury (sTBI) is a condition of increasing epidemiologic concern worldwide. Outcomes are worse as observed in low- and middle-income countries (LMICs) versus high-income countries. Global targets are in place to address the surgical burden of disease. At the same time, most of the published literature and evidence on the clinical approach to sTBI comes from wealthy areas with an abundance of resources. The available paradigms, including the Brain Trauma Foundation guidelines, the Seattle International Severe Traumatic Brain Injury Consensus Conference, Consensus Revised Imaging and Clinical Examination, and multimodality approaches, may fit differently depending on local resources, expertise, and sociocultural factors. A first step toward addressing heterogeneity in practice is to consider comparative effectiveness approaches that can capture actual practice patterns and record short-term and long-term outcomes of interest. Decompressive craniectomy (DC) decreases intracranial pressure burden and can be lifesaving. Nevertheless, completed randomized controlled trials took place within high-income settings, leaving important questions unanswered and making extrapolations to LMICs questionable. The concept of preemptive DC specifically to address limited neuromonitoring resources may warrant further study to establish a benefit/risk profile for the procedure and its role within local protocols of care.
Collapse
Affiliation(s)
- Ronald Alvarado-Dyer
- Division of Neurocritical Care, Departments of Neurology, and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637 USA
| | - Sergio Aguilera
- Neurosurgery, Herminda Martin Hospital-Chillán Valparaíso University, Valparaíso, Chile
| | | | - Walter Videtta
- Intensive Care, Posadas Hospital, Buenos Aires, Argentina
| | - Danilo Fischer
- Intensive Care, School of Medicine, Universidad de los Andes, Santiago, Chile
| | - Manuel Jibaja
- Intensive Care, Hospital Eugenio Espejo, School of Medicine, Universidad San Francisco de Quito, Quito, Ecuador
| | | | - Roxanna M. Garcia
- Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Fernando D. Goldenberg
- Division of Neurocritical Care, Departments of Neurology, and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637 USA
| | - Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology, and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637 USA
| |
Collapse
|
19
|
Lazaridis C, Ajith A, Mansour A, Okonkwo DO, Diaz-Arrastia R, Mayampurath A, Arrastia RD, Temkin N, Moore C, Shutter L, Madden C, Andaluz N, Okonkwo D, Chesnut R, Bullock R, McGregor J, Grant G, Shapiro M, Weaver M, LeRoux P, Jallo J. Prediction of Intracranial Hypertension and Brain Tissue Hypoxia Utilizing High-Resolution Data from the BOOST-II Clinical Trial. Neurotrauma Rep 2022; 3:473-478. [PMID: 36337077 PMCID: PMC9622207 DOI: 10.1089/neur.2022.0055] [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] [Indexed: 11/05/2022] Open
Abstract
The current approach to intracranial hypertension and brain tissue hypoxia is reactive, based on fixed thresholds. We used statistical machine learning on high-frequency intracranial pressure (ICP) and partial brain tissue oxygen tension (PbtO2) data obtained from the BOOST-II trial with the goal of constructing robust quantitative models to predict ICP/PbtO2 crises. We derived the following machine learning models: logistic regression (LR), elastic net, and random forest. We split the data set into 70–30% for training and testing and utilized a discrete-time survival analysis framework and 5-fold hyperparameter optimization strategy for all models. We compared model performances on discrimination between events and non-events of increased ICP or low PbtO2 with the area under the receiver operating characteristic (AUROC) curve. We further analyzed clinical utility through a decision curve analysis (DCA). When considering discrimination, the number of features, and interpretability, we identified the RF model that combined the most recent ICP reading, episode number, and longitudinal trends over the preceding 30 min as the best performing for predicting ICP crisis events within the next 30 min (AUC 0.78). For PbtO2, the LR model utilizing the most recent reading, episode number, and longitudinal trends over the preceding 30 min was the best performing (AUC, 0.84). The DCA showed clinical usefulness for wide risk of thresholds for both ICP and PbtO2 predictions. Acceptable alerting thresholds could range from 20% to 80% depending on a patient-specific assessment of the benefit-risk ratio of a given intervention in response to the alert.
Collapse
Affiliation(s)
- Christos Lazaridis
- Departments of Neurology and Neurosurgery, University of Chicago Medical Center, University of Chicago, Chicago, Illinois, USA
| | - Aswathy Ajith
- Department of Computer Science, University of Chicago, Chicago, Illinois, USA
| | - Ali Mansour
- Departments of Neurology and Neurosurgery, University of Chicago Medical Center, University of Chicago, Chicago, Illinois, USA
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anoop Mayampurath
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Lazaridis C. Normothermic regional perfusion: Ethically not merely permissible but recommended. Am J Transplant 2022; 22:2285-2286. [PMID: 35451186 DOI: 10.1111/ajt.17066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/19/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Christos Lazaridis
- Department of Neurology, MacLean Center for Clinical Ethics, University of Chicago Medical Center, Chicago, Illinois, USA
| |
Collapse
|
21
|
Lazaridis C. Defining Death Behind the Veil of Ignorance. The Journal of Clinical Ethics 2022. [DOI: 10.1086/jce2022332130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
22
|
Lazaridis C. In Reply to the Letter to the Editor Regarding "Decompressive Craniectomy After Traumatic Brain Injury: Incorporating Patient Preferences into Decision Making". World Neurosurg 2022; 160:124. [PMID: 35364669 DOI: 10.1016/j.wneu.2022.01.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, Chicago, Illinois, USA.
| |
Collapse
|
23
|
Loggini A, Kass-Hout T, Awad IA, El Ammar F, Kramer CL, Goldenberg FD, Lazaridis C, Mansour A. Case Report: Management of Traumatic Carotid-Cavernous Fistulas in the Acute Setting of Penetrating Brain Injury. Front Neurol 2022; 12:715955. [PMID: 35222224 PMCID: PMC8879509 DOI: 10.3389/fneur.2021.715955] [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: 05/27/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022] Open
Abstract
Traumatic carotid-cavernous fistulas (tCCFs) after penetrating brain injury (PBI) have been uncommonly described in the literature with little guidance on optimal treatment. In this case series, we present two patients with PBI secondary to gunshot wounds to the head who acutely developed tCCFs, and we review the lead-up to diagnosis in addition to the treatment of this condition. We highlight the importance of early cerebrovascular imaging as the clinical manifestations may be limited by poor neurological status and possibly concomitant injury. Definitive treatment should be attempted as soon as possible with embolization of the fistula, flow diversion via stenting of the fistula site, and, finally, vessel sacrifice as possible therapeutic options.
Collapse
Affiliation(s)
- Andrea Loggini
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Tareq Kass-Hout
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Issam A. Awad
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Faten El Ammar
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Christopher L. Kramer
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Fernando D. Goldenberg
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Ali Mansour
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- *Correspondence: Ali Mansour
| |
Collapse
|
24
|
Omelianchuk A, Bernat J, Caplan A, Greer D, Lazaridis C, Lewis A, Pope T, Ross LF, Magnus D. Revise the UDDA to Align the Law with Practice through Neuro-Respiratory Criteria. Neurology 2022; 98:532-536. [PMID: 35078943 PMCID: PMC8967425 DOI: 10.1212/wnl.0000000000200024] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/06/2022] [Indexed: 11/15/2022] Open
Abstract
Although the Uniform Determination of Death Act (UDDA) has served as a model statute for 40 years, there is a growing recognition that the law must be updated. One issue being considered by the Uniform Law Commission's Drafting Committee to revise the UDDA is whether the text “all functions of the entire brain, including the brainstem” should be changed. Some argue that the absence of diabetes insipidus indicates that some brain functioning continues in many individuals who otherwise meet the “accepted medical standards” like the American Academy of Neurology's. The concern is that the legal criteria and the medical standards used to determine death by neurologic criteria are not aligned. We argue for the revision of the UDDA to more accurately specify legal criteria that align with the medical standards: brain injury leading to permanent loss of the capacity for consciousness, the ability to breathe spontaneously, and brainstem reflexes. We term these criteria neurorespiratory criteria and show that they are well-supported in the literature for physiologic and social reasons justifying their use in the law.
Collapse
Affiliation(s)
- Adam Omelianchuk
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - James Bernat
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - Arthur Caplan
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - David Greer
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - Christos Lazaridis
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - Ariane Lewis
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - Thaddeus Pope
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - Lainie Friedman Ross
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL
| | - David Magnus
- From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL.
| |
Collapse
|
25
|
Lazaridis C. Defining Death Behind the Veil of Ignorance. J Clin Ethics 2022; 33:130-140. [PMID: 35731817] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In this article I examine the question of how a liberal state should go about defining death. Plausible standards for a definition of death include a somatic one based on circulatory criteria, death by neurologic criteria (DNC), and higher brain death. I will argue that Rawlsian "burdens of judgment" apply in this process: that is, reasonable disagreement should be expected on important topics, and such disagreement ought not be resolved via the coercive powers of the state. Nevertheless, the state must legislate a definition of death, and in doing so faces a "neutralist dilemma," that is, when there are multiple reasonable ways to move forward, only one can be chosen. I will examine a possible way to exit this neutralist dilemma. Finally, I will argue for DNC as the normatively preferred default definition of death. To do this, I will employ the Rawlsian heuristic of the "original position" and offer public reasons in favor of using DNC as the preferred default definition of death.
Collapse
Affiliation(s)
- Christos Lazaridis
- Associate Professor of Neurology in the Departments of Neurology, and Neurosur-gery, MacLean Center for Clinical Ethics, University of Chicago Medicine, in Chicago, Illinois USA.
| |
Collapse
|
26
|
Mansour A, Fuhrman JD, Ammar FE, Loggini A, Davis J, Lazaridis C, Kramer C, Goldenberg FD, Giger ML. Machine Learning for Early Detection of Hypoxic-Ischemic Brain Injury After Cardiac Arrest. Neurocrit Care 2021; 36:974-982. [PMID: 34873672 PMCID: PMC8647961 DOI: 10.1007/s12028-021-01405-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 11/16/2021] [Indexed: 11/25/2022]
Abstract
Background Establishing whether a patient who survived a cardiac arrest has suffered hypoxic-ischemic brain injury (HIBI) shortly after return of spontaneous circulation (ROSC) can be of paramount importance for informing families and identifying patients who may benefit the most from neuroprotective therapies. We hypothesize that using deep transfer learning on normal-appearing findings on head computed tomography (HCT) scans performed after ROSC would allow us to identify early evidence of HIBI. Methods We analyzed 54 adult comatose survivors of cardiac arrest for whom both an initial HCT scan, done early after ROSC, and a follow-up HCT scan were available. The initial HCT scan of each included patient was read as normal by a board-certified neuroradiologist. Deep transfer learning was used to evaluate the initial HCT scan and predict progression of HIBI on the follow-up HCT scan. A naive set of 16 additional patients were used for external validation of the model. Results The median age (interquartile range) of our cohort was 61 (16) years, and 25 (46%) patients were female. Although findings of all initial HCT scans appeared normal, follow-up HCT scans showed signs of HIBI in 29 (54%) patients (computed tomography progression). Evaluating the first HCT scan with deep transfer learning accurately predicted progression to HIBI. The deep learning score was the most significant predictor of progression (area under the receiver operating characteristic curve = 0.96 [95% confidence interval 0.91–1.00]), with a deep learning score of 0.494 having a sensitivity of 1.00, specificity of 0.88, accuracy of 0.94, and positive predictive value of 0.91. An additional assessment of an independent test set confirmed high performance (area under the receiver operating characteristic curve = 0.90 [95% confidence interval 0.74–1.00]). Conclusions Deep transfer learning used to evaluate normal-appearing findings on HCT scans obtained early after ROSC in comatose survivors of cardiac arrest accurately identifies patients who progress to show radiographic evidence of HIBI on follow-up HCT scans.
Collapse
Affiliation(s)
- Ali Mansour
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
- Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Jordan D Fuhrman
- Department of Radiology, University of Chicago, 5841 S. Maryland Ave., Chicago, IL, 60637-1470, USA
| | - Faten El Ammar
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
| | - Andrea Loggini
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
| | - Jared Davis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
- Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Christopher Kramer
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA
- Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Fernando D Goldenberg
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL, 60637-1470, USA.
- Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Maryellen L Giger
- Department of Radiology, University of Chicago, 5841 S. Maryland Ave., Chicago, IL, 60637-1470, USA.
| |
Collapse
|
27
|
Lazaridis C, Goldenberg FD, Mansour A, Kramer C, Tate A. What Does Coma Mean? Implications for Shared Decision Making in Acute Brain Injury. World Neurosurg 2021; 158:e377-e385. [PMID: 34763107 DOI: 10.1016/j.wneu.2021.10.185] [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] [Received: 09/03/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Insufficient attention has been devoted to shared decision-making (SDM) in the setting of acute brain injury (ABI). Communication occupies a central role that has been highlighted in recent research on SDM with brain injured patients, with respect to "the impact of specific clinician words and expressions". In this investigation, we seek to understand lay public understandings of the term "coma." METHODS Qualitative analysis of lay interpretations of the term "cComa" using modified open coding of a free-text response question at the end of a survey exploring public attitudes in the context of hypothetical ABI. Respondents (n = 511) were drawn from a convenience sample using Amazon Mechanical Turk. This analysis focuses on respondents' free-text responses to the question: "When doctors say a patient is in a coma, what does that mean?" RESULTS We analyzed 206 unique responses in order to derive emergent lay conceptualizations of coma. The following 4 themes emerged in how respondents understood coma: (1) State descriptive. (2) Marker of injury severity. (3) As in distinction (or lack thereof) from brain death or sleep. (4) Covert consciousness. For each concept, we discuss its salient elements and offer representative quotes. CONCLUSIONS This study provides preliminary qualitative evidence of lay public understandings of the neurologic term "coma". These findings can have implications for surrogate/family-clinician communications. While a physician may intend "coma" to convey a technical description, a family member or surrogate may interpret it as a very different activity (e.g., prognostication, emotional signaling), setting the stage for miscommunication.
Collapse
Affiliation(s)
- Christos Lazaridis
- Departments of Neurology and Neurosurgery, Neurocritical Care Unit, The University of Chicago, Chicago, Illinois, USA.
| | - Fernando D Goldenberg
- Departments of Neurology and Neurosurgery, Neurocritical Care Unit, The University of Chicago, Chicago, Illinois, USA
| | - Ali Mansour
- Departments of Neurology and Neurosurgery, Neurocritical Care Unit, The University of Chicago, Chicago, Illinois, USA
| | - Christopher Kramer
- Departments of Neurology and Neurosurgery, Neurocritical Care Unit, The University of Chicago, Chicago, Illinois, USA
| | - Alexandra Tate
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
28
|
Tachmatzidis D, Filos D, Tsarouchas A, Mouselimis D, Bakogiannis C, Antoniadis A, Chouvarda I, Lazaridis C, Triantafyllou C, Fragkakis N, Maglaveras N, Vassilikos V. Beat-to-beat P-wave analysis outperforms conventional P-wave indices in identifying patients with a history of paroxysmal atrial fibrillation, during sinus rhythm. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0306] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Atrial fibrillation (AF) is the most common arrhythmia and is associated with high risk of morbidity and mortality. In many patients, AF is of episodic character (paroxysmal AF – PAF), which makes the identification of these patients during sinus rhythm (SR) challenging.
Purpose
The aim of the present study is to compare the performance of beat-to-beat P-wave analysis with P-wave indices used as predictors of PAF, such as P-wave duration, area, voltage, axis, terminal force in V1, inter-atrial block or orthogonal type, in identifying patients with history of PAF during sinus rhythm.
Methods
Standard 12-lead ECG and 10-minute orthogonal ECG recordings were obtained from 40 consecutive patients with short history of PAF under no antiarrhythmic medication and 60 age- and sex- matched healthy controls. The P-waves on the 10-minute recordings were analyzed on a beat-to-beat basis and classified as belonging to a primary or secondary morphology according to previous study. Wavelet transform used to further analyze P-wave orthogonal signals of main morphology on a beat-to-beat basis.
Results
38 out of 327 studied features were found to differ significantly among the two groups. These features were tested for their diagnostic ability and receiver operating characteristic curves were ploted. Only 3 of them performed adequetly, with an area under curve (AUC) above 0.65; Two of them came from morphology analysis (percentage of beats following main morphology in axis X and Y) and one from wavelet analysis (max energy in high frequency zone -Y axis). Among standard P-wave indices, P-wave area in lead II was the one with the highest AUC (0.64).
Conclusion
Novel indices derived from beat-to-beat analysis outperform stadard P-wave markers in identifying patients with PAF history during sinus rhythm.
Funding Acknowledgement
Type of funding sources: None. ROC curves of most significant featuresAUC characteristics of P-wave indices
Collapse
Affiliation(s)
- D Tachmatzidis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - D Filos
- Aristotle University of Thessaloniki, Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Thessaloniki, Greece
| | - A Tsarouchas
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - D Mouselimis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - C Bakogiannis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - A Antoniadis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - I Chouvarda
- Aristotle University of Thessaloniki, Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Thessaloniki, Greece
| | - C Lazaridis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - C Triantafyllou
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - N Fragkakis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - N Maglaveras
- Aristotle University of Thessaloniki, Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Thessaloniki, Greece
| | - V Vassilikos
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| |
Collapse
|
29
|
Lazaridis C, Mansour A, Singh M. Decompressive Craniectomy After Traumatic Brain Injury: Incorporating Patient Preferences into Decision-Making. World Neurosurg 2021; 157:e327-e332. [PMID: 34648983 DOI: 10.1016/j.wneu.2021.10.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/05/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Decompressive craniectomy (DC) is highly effective in relieving intracranial hypertension; however, patient selection, intracranial pressure threshold, timing, and long-term functional outcomes are all subject to controversy. Recently, recommendations were made to update the Brain Trauma Foundation guidelines in regards to the use of DC based on the DECRA (Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury) and RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) clinical trials. Neither the updated recommendations, nor the aforementioned trials, provide a method in incorporating individualized patient or surrogate decision-maker preferences into decision making. METHODS In this manuscript, we aimed to redress the gap of not incorporating patient preferences in such value-laden decision making as in the case of DC for refractory post-traumatic intracranial hypertension. We proposed a decision aid based on principles of Decision Theory, and specifically of Expected Utility Theory. RESULTS We showed that 1) early secondary DC as studied in DECRA, and based on the 1-year outcome data, is associated with decreased expected utility for all possible preference rankings of outcomes; and 2) recommending a late secondary DC versus tier-3 medical therapy, as studied in RESCUEicp, should be informed by individualized patient preference rankings of outcomes as elicited via shared decision-making. CONCLUSIONS The 1-year outcomes from DECRA and RESCUEicp have served as the basis for updated guidelines. However, unaided interpretation of trial data may not be adequate for individualized decision-making; we suggest that the latter can be significantly supported by decision aids such as the one described here and based on expected utility theory.
Collapse
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, Chicago, Illinois, USA.
| | - Ali Mansour
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Manasvini Singh
- Health Economics, College of Social and Behavioral Science, University of Massachusetts, Amherst, Massachusetts, USA
| |
Collapse
|
30
|
Mansour A, Loggini A, El Ammar F, Alvarado-Dyer R, Polster S, Stadnik A, Das P, Warnke PC, Yamini B, Lazaridis C, Kramer C, Mould WA, Hildreth M, Sharrock M, Hanley DF, Goldenberg FD, Awad IA. Post-Trial Enhanced Deployment and Technical Performance with the MISTIE Procedure per Lessons Learned. J Stroke Cerebrovasc Dis 2021; 30:105996. [PMID: 34303090 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/04/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We hypothesize that procedure deployment rates and technical performance with minimally invasive surgery and thrombolysis for intracerebral hemorrhage (ICH) evacuation (MISTIE) can be enhanced in post-trial clinical practice, per Phase III trial results and lessons learned. MATERIALS AND METHODS We identified ICH patients and those who underwent MISTIE procedure between 2017-2021 at a single site, after completed enrollments in the Phase III trial. Deployment rates, complications and technical outcomes were compared to those observed in the trial. Initial and final hematoma volume were compared between site measurements using ABC/2, MISTIE trial reading center utilizing manual segmentation, and a novel Artificial Intelligence (AI) based volume assessment. RESULTS Nineteen of 286 patients were eligible for MISTIE. All 19 received the procedure (6.6% enrollment to screening rate 6.6% compared to 1.6% at our center in the trial; p=0.0018). Sixteen patients (84%) achieved evaculation target < 15 mL residual ICH or > 70% removal, compared to 59.7% in the trial surgical cohort (p=0.034). No poor catheter placement occurred and no surgical protocol deviations. Limitations of ICH volume assessments using the ABC/2 method were shown, while AI based methodology of ICH volume assessments had excellent correlation with manual segmentation by experienced reading centers. CONCLUSIONS Greater procedure deployment and higher technical success rates can be achieved in post-trial clinical practice than in the MISTIE III trial. AI based measurements can be deployed to enhance clinician estimated ICH volume. Clinical outcome implications of this enhanced technical performance cannot be surmised, and will need assessment in future trials.
Collapse
Affiliation(s)
- Ali Mansour
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Andrea Loggini
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Faten El Ammar
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Ronald Alvarado-Dyer
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Sean Polster
- Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Agnieszka Stadnik
- Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Paramita Das
- Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Peter C Warnke
- Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Bakhtiar Yamini
- Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christopher Kramer
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - W Andrew Mould
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA.
| | - Meghan Hildreth
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA.
| | - Matthew Sharrock
- Division of Neurocritical Care, Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA.
| | - Fernando D Goldenberg
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Issam A Awad
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| |
Collapse
|
31
|
|
32
|
Tachmatzidis D, Filos D, Tsarouchas A, Mouselimis D, Antoniadis A, Bakogiannis C, Chouvarda I, Lazaridis C, Triantafyllou C, Fragkakis N, Maglaveras N, Vassilikos V. P-wave beat-to-beat morphology analysis outperforms conventional P-wave indices in detecting patients with paroxysmal atrial fibrillation. Europace 2021. [DOI: 10.1093/europace/euab116.167] [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: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Atrial fibrillation (AF) - the most common sustained cardiac arrhythmia - while not a life-threatening condition itself, leads to an increased risk of stroke and high rates of mortality. Early detection and diagnosis of AF is a critical issue for all health stakeholders.
Purpose
The aim of this study is to compare the performance of standard P-wave indices with beat-to-beat P-wave morphological variability parameters in identifying patients with history of Paroxysmal Atrial Fibrillation (PAF).
Methods
Three-dimensional 1000Hz ECG digital recordings of 10 minutes duration were obtained from a total of 39 PAF patients and 60 healthy individuals. Following artifacts and ectopic beats removal, P‑wave morphology analysis was performed based on the dynamic application of the k‑means clustering process and main and secondary P-wave morphologies were identified. The percentage of P-waves following the main or the secondary morphology in each lead was calculated, as well as established indices such as Advanced Interatrial Block, P-wave duration, axis and area, P-wave Terminal Force in lead V1 and Orthogonal Leads Type 1, 2 or 3.
Results
9 out of 24 parameters studied, were found to be significantly different between the two groups. 7 of these indices were derived from morphology analysis and 2 from P-wave area. Logistic regression revealed that the percentage of P-waves allocated to main morphology in X axis performed better than all other indices in identifying patients with PAF history from healthy volunteers in terms of total accuracy and F1 measure.
Conclusion
P-wave beat-to-beat morphology analysis can identify PAF patients during normal sinus rhythm more efficiently than standard P-wave indices. Abstract Figure.
Collapse
Affiliation(s)
- D Tachmatzidis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - D Filos
- Aristotle University of Thessaloniki, Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Thessaloniki, Greece
| | - A Tsarouchas
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - D Mouselimis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - A Antoniadis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - C Bakogiannis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - I Chouvarda
- Aristotle University of Thessaloniki, Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Thessaloniki, Greece
| | - C Lazaridis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - C Triantafyllou
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - N Fragkakis
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| | - N Maglaveras
- Aristotle University of Thessaloniki, Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Thessaloniki, Greece
| | - V Vassilikos
- Aristotle University of Thessaloniki, 3rd Cardiology Department, Thessaloniki, Greece
| |
Collapse
|
33
|
Tsarouchas A, Bakogiannis C, Mouselimis D, Lazaridis C, Kelemanis I, Theofillogiannakos EK, Pagourelias ED, Papadopoulos CE, Fragakis N, Vassilikos VP. HFrEF patient activity levels during COVID-19 lockdown: A comparison between physical activity questionnaires and implantable devices data. Eur J Prev Cardiol 2021. [PMCID: PMC8136071 DOI: 10.1093/eurjpc/zwab061.032] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Funding Acknowledgements Type of funding sources: None. Background The ongoing COVID-19 pandemic is a major public health crisis of great risk to patients with cardiovascular comorbidities. Heart failure (HF) is a deadly chronic disease, a leading cause of hospitalizations worldwide and a great detriment to patients’ quality of life. HF therapy guidelines suggest prescribing physical activity to improve long-term outcomes. Self- or government- imposed behavioral modifications in response to COVID-19 ranging from avoiding social interactions to outright restrictions of movement (lockdowns) could compromise regular PA in HF patients, who constitute an extremely high-risk group. Purpose Investigate the effect of the national lockdown in Greece 23rd March – 4th May 2020) on the PA levels of patients suffering from HF with reduced ejection fraction (HFrEF) and cardiac implantable electronic devices (CIEDs). Methods HFrEF patients with CIEDs were included in the study. Participants answered the Physical Activity Questionnaire (PAQ) regarding the period before, during and after the 42-day national lockdown. CIED-derived daily activity levels for the corresponding periods were recorded through CIED telemetry. The differences in PAQ- and CIED-derived PA levels and sedentary time before, during and after the lockdown period were investigated. Results 67 HFrEF patients participated in the study (mean age 69 ± 10.2y, 85% male). Activity levels fell in 55 (82%) of patients. The median PAQ-derived PA level decreased by 28% during lockdown, from 840.5 (944) METmin/week to 602 (1054) METmin/week during the lockdown (p = 0.01). A 53% increase was observed after the lockdown, to 924 (1214) METmin/week (p = 0.004). The CIED-derived activity level was 2.38 (1.3) hours/day pre-lockdown, 1.78 (1.1) hours/day during the lockdown (25% decrease, p < 0.001) and 2.69 (1.5) hours/day post-lockdown (51% increase, p < 0.001). Time spent on sedentary activities also increased to 9 (3) hours per day during the lockdown, up from 6.5 (4) hours before lockdown (p = 0.001). Conclusions All measures examined in this study indicate that the COVID-19 lockdown period was associated with a significant decrease in HFrEF patients’ PA. All efforts must be made on the part of clinicians and public health organizations to promote safe exercise in this subgroup of the population that is particularly vulnerable to the effects of a sedentary lifestyle. Abstract Figure. Patient activity around COVID lockdown ![]()
Collapse
Affiliation(s)
- A Tsarouchas
- Hippokration General Hospital of Thessaloniki, Third Cardiology Department AUTh, Thessaloniki, Greece
| | - C Bakogiannis
- Hippokration General Hospital of Thessaloniki, Third Cardiology Department AUTh, Thessaloniki, Greece
| | - D Mouselimis
- Hippokration General Hospital of Thessaloniki, Third Cardiology Department AUTh, Thessaloniki, Greece
| | - C Lazaridis
- Hippokration General Hospital of Thessaloniki, Third Cardiology Department AUTh, Thessaloniki, Greece
| | - I Kelemanis
- Hippokration General Hospital of Thessaloniki, Third Cardiology Department AUTh, Thessaloniki, Greece
| | - EK Theofillogiannakos
- Hippokration General Hospital of Thessaloniki, Third Cardiology Department AUTh, Thessaloniki, Greece
| | - ED Pagourelias
- Hippokration General Hospital of Thessaloniki, Third Cardiology Department AUTh, Thessaloniki, Greece
| | - CE Papadopoulos
- Hippokration General Hospital of Thessaloniki, Third Cardiology Department AUTh, Thessaloniki, Greece
| | - N Fragakis
- Hippokration General Hospital of Thessaloniki, Third Cardiology Department AUTh, Thessaloniki, Greece
| | - VP Vassilikos
- Hippokration General Hospital of Thessaloniki, Third Cardiology Department AUTh, Thessaloniki, Greece
| |
Collapse
|
34
|
Lazaridis C, Mouselimis D, Bakogiannis C, Tsarouchas A, Antoniadis A, Papadopoulos CE, Tzikas S, Fragakis N, Vassilikos VP. The role of the novel MyAlgos e-medicine Platform in promoting patient-centered self-care management in patients with atrial fibrillation: The emPOWERD trial. Eur J Prev Cardiol 2021. [DOI: 10.1093/eurjpc/zwab061.432] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
The emergence of digital health has revolutionized most aspects of healthcare. Meanwhile, atrial fibrillation (AF) remains the most common sustained arrhythmia associated with high morbidity and impaired quality of life. Patient-perceived treatment burden can be further optimized by digital health interventions utilizing smartphone technology.
The MyAlgos platform is an integrated software system designed to enhance the remote management and communication between the patient and the healthcare practitioner. The mobile application encourages patient self-management through educational modules and tools to improve medication adherence. The web-based platform allows the health care practitioner to receive live updates on patient status and design personalized self-care management plans.
Purpose
To investigate whether the use of the MyAlgos platform by AF patients is safe and improves the quality of self-care, quality of life (QoL), and hospitalization rate.
Methods
We designed a single-center, randomized, controlled, prospective, open-label, pilot study to compare the effect of the use of the full-feature MyAlgos platform version versus a stripped-down control version of the platform on the QoL, medication adherence and hospitalization rate in patients with paroxysmal AF. The full version of the e-medicine platform includes active patient education, communication with the medical team, medication reminders as well as the full record of clinically significant data such as heart rate and blood pressure. Specialized algorithms monitor patient data and alert physicians for potential AF episodes. The control version only allows the recording of patient’s heart rate.
Results
A total of 80 patients with paroxysmal AF were randomized in a 1:1 ratio to receive either the full or the control version of the MyAlgos Platform. The mean age of all patients, 53 (66%) male, was 58.1 ± 9.1 years. Hypertension and diabetes were present in 47 (59%) and 7 (9%) respectively. At baseline, the majority of patients had AF-related symptoms classified as European Heart Rhythm Association (EHRA) I (45%) or EHRA II (24%), while the mean Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) score was 70.1 ± 17.0. Between the two groups, there were no statistically significant differences in the baseline characteristics of the participants.
Conclusion
The emPOWERD trial will provide data on the impact of a novel e-medicine platform on the QoL, medication adherence and hospitalizations of patients with paroxysmal AF. We anticipate better outcomes for the subjects receiving the full version of the MyAlgos platform, allowing it to positively affect the further management of paroxysmal AF.
Abstract Figure. The MyAlgos e-medicine Platform
Collapse
Affiliation(s)
- C Lazaridis
- Hippokration University Hospital, Aristotle University of Thessaloniki, Third Cardiology Department, Thessaloniki, Greece
| | - D Mouselimis
- Hippokration University Hospital, Aristotle University of Thessaloniki, Third Cardiology Department, Thessaloniki, Greece
| | - C Bakogiannis
- Hippokration University Hospital, Aristotle University of Thessaloniki, Third Cardiology Department, Thessaloniki, Greece
| | - A Tsarouchas
- Hippokration University Hospital, Aristotle University of Thessaloniki, Third Cardiology Department, Thessaloniki, Greece
| | - A Antoniadis
- Hippokration University Hospital, Aristotle University of Thessaloniki, Third Cardiology Department, Thessaloniki, Greece
| | - CE Papadopoulos
- Hippokration University Hospital, Aristotle University of Thessaloniki, Third Cardiology Department, Thessaloniki, Greece
| | - S Tzikas
- Hippokration University Hospital, Aristotle University of Thessaloniki, Third Cardiology Department, Thessaloniki, Greece
| | - N Fragakis
- Hippokration University Hospital, Aristotle University of Thessaloniki, Third Cardiology Department, Thessaloniki, Greece
| | - VP Vassilikos
- Hippokration University Hospital, Aristotle University of Thessaloniki, Third Cardiology Department, Thessaloniki, Greece
| |
Collapse
|
35
|
Loggini A, Mansour A, El Ammar F, Tangonan R, Kramer CL, Goldenberg FD, Lazaridis C. Inversion of T Waves on Admission is Associated with Mortality in Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105776. [PMID: 33839377 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Cardiac dysfunction directly caused by spontaneous intracerebral hemorrhage (ICH) is a poorly understood phenomenon, and its impact on outcome is still uncertain. The aim of this study is to investigate the relationship between electrocardiographic (EKG) abnormalities and mortality in ICH. METHODS This is a retrospective study analyzing EKG patterns on admission in patients admitted with ICH at a tertiary care center over an eight-year period. For each patient, demographics, medical history, clinical presentation, EKG on admission and during hospitalization, and head CT at presentation were reviewed. Mortality was noted. RESULTS A total of 301 ICH patients were included in the study. The most prevalent EKG abnormalities were QTc prolongation in 56% of patients (n = 168) followed by inversion of T waves (TWI) in 37% of patients (n = 110). QTc prolongation was associated with ganglionic location (p = 0.03) and intraventricular hemorrhage (IVH) (p = 0.01), TWIs were associated with ganglionic location (p = 0.02), and PR prolongation was associated with IVH (p = 0.01), while QRS prolongation was associated with lobar location (p < 0.01). Volume of ICH, hemispheric laterality, and involvement of insular cortex were not correlated with specific EKG patterns. In a logistic regression model, after correcting for ICH severity and prior cardiac history, presence of TWI was independently associated with mortality (OR: 3.04, CI:1.6-5.8, p < 0.01). Adding TWI to ICH score improved its prognostic accuracy (AUC 0.81, p = 0.04). Disappearance of TWI during hospitalization did not translate into improvement of survival (p = 0.5). CONCLUSION Presence of TWI on admission is an independent and unmodifiable factor associated with mortality in ICH. Further research is needed to elucidate the pathophysiologic mechanisms underlying electrocardiographic changes after primary intracerebral hemorrhage.
Collapse
Affiliation(s)
- Andrea Loggini
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Ali Mansour
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA; Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Faten El Ammar
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Ruth Tangonan
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Christopher L Kramer
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA; Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Fernando D Goldenberg
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA; Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA; Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| |
Collapse
|
36
|
Lazaridis C, Mansour A. To Decompress or Not? An Expected Utility Inspired Approach To Shared decision-making For Supratentorial Ischemic Stroke. Neurocrit Care 2021; 34:709-713. [PMID: 33604879 DOI: 10.1007/s12028-021-01198-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
Patients with large territorial supratentorial infarctions are at high risk of cerebral edema, increased intracranial pressure, tissue herniation and death. There is strong evidence supporting prompt decompressive craniectomy after large hemispheric ischemic stroke as a means to reduce mortality. Nevertheless, functional outcomes can vary significantly. Clinical trials have traditionally judged these outcomes by a priori dichotomization without taking into account individual patient and caregiver preferences. If these are not incorporated into shared decision-making, there are significant risks in both directions, i.e. producing outcomes that may be judged as unacceptable to survivors, or not offering life-saving treatments to patients that according to their own values could be beneficial. In the absence of decision aids, we explore insights from decision theory and propose an expected utility-inspired approach as a supplementary navigating tool in the decision-making process. Four patient case scenarios are discussed as a demonstration of using individualized rankings of outcome preferences, and deriving expected utilities for interventions such as decompressive craniectomy versus medical therapy. The ultimate aim of the suggested approach is to assure that patient values are elicited and incorporated, and possible range and nature of outcomes are discussed, and by attempting to connect best available means to patient individualized ends.
Collapse
Affiliation(s)
- Christos Lazaridis
- Neurocritical Care Unit, Departments of Neurology, and Surgery (Section of Neurosurgery), University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, USA.
| | - Ali Mansour
- Neurocritical Care Unit, Departments of Neurology, and Surgery (Section of Neurosurgery), University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, USA
| |
Collapse
|
37
|
Loggini A, El Ammar F, Darzi AJ, Mansour A, Kramer CL, Goldenberg FD, Lazaridis C. Effect of desmopressin on hematoma expansion in antiplatelet-associated intracerebral hemorrhage: A systematic review and meta-analysis. J Clin Neurosci 2021; 86:116-121. [PMID: 33775314 DOI: 10.1016/j.jocn.2021.01.017] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
The purpose of this study was to perform a systematic review and meta-analysis on the effect of desmopressin on hematoma expansion (HE) in antiplatelet-associated intracerebral hemorrhage (AA-ICH). Secondary outcomes examined were the rate of thrombotic complications and neurologic outcome. Three databases were searched (Pubmed, Scopus, and Cochrane) for randomized clinical trials and controlled studies comparing desmopressin versus controls in adult patients with AA-ICH. The Mantel-Haenszel method was applied to calculate an overall effect estimate for each outcome by combining stratum-specific risk ratio (RR). Risk of bias was computed using the Newcastle-Ottawa Scale. The protocol was registered in PROSPERO (42020190234). Three retrospective controlled studies involving 263 patients were included in the meta-analysis. Compared to controls, desmopressin was associated with a non-significant reduction in HE (19.1% vs. 30%; RR:0.61; 95%CI, 0.27-1.39; P = 0.24), a similar rate of thrombotic events (5.5% vs. 9.9%; RR:0.47; 95%CI, 0.17-1.31; P = 0.15), and significantly worse neurologic outcome (mRS ≥ 4) (66.3% vs. 50%; RR:1.36; 95%CI, 1.08-1.7; P = 0.008). Qualitative analysis of included studies for each outcome revealed low to moderate risk of bias. The available literature does not support the routine use of desmopressin in the setting of AA-ICH. Until larger prospective trials are performed, the administration of desmopressin should be judiciously considered on a case-by-case basis.
Collapse
Affiliation(s)
- Andrea Loggini
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Faten El Ammar
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Andrea J Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ali Mansour
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Christopher L Kramer
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Fernando D Goldenberg
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Christos Lazaridis
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| |
Collapse
|
38
|
Affiliation(s)
- Christos Lazaridis
- Neurocritical Care, University of Chicago Medical Center, Chicago, Illinois
| | - L Syd M Johnson
- Center for Bioethics and Humanities, Upstate Medical University, Syracuse, New York
| |
Collapse
|
39
|
Affiliation(s)
- Christos Lazaridis
- Departments of Neurology and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Ave. MC 2030, Chicago, IL, 60637, USA.
| |
Collapse
|
40
|
Lazaridis C, Desai M, Johnson LSM. Communication and Well-Being Considerations in Disorders of Consciousness. Neurocrit Care 2021; 34:701-703. [PMID: 33479918 DOI: 10.1007/s12028-020-01175-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/04/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Christos Lazaridis
- Neurocritical Care Unit, Department of Neurology, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA.
- Section of Neurosurgery, University of Chicago Medical Center, Chicago, IL, USA.
| | - Masoom Desai
- Division of Neurocritical Care, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
- Division of Neurophysiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - L Syd M Johnson
- Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, NY, USA
| |
Collapse
|
41
|
Mansour A, Loggini A, Goldenberg FD, Kramer C, Naidech AM, Ammar FE, Vasenina V, Castro B, Das P, Horowitz PM, Karrison T, Zakrison T, Hampton D, Rogers SO, Lazaridis C. Coagulopathy as a Surrogate of Severity of Injury in Penetrating Brain Injury. J Neurotrauma 2021; 38:1821-1826. [PMID: 33238820 DOI: 10.1089/neu.2020.7422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 11/12/2022] Open
Abstract
Penetrating brain injury (PBI) is the most devastating type of traumatic brain injury. Development of coagulopathy in the acute setting of PBI, though common, remains of unclear significance as does its reversal. The aim of this study is to investigate the relationship between coagulopathy and clinical presentation, radiographical features, and outcome in civilian patients with PBI. Eighty-nine adult patients with PBI at a Level I trauma center in Chicago, Illinois who survived acute resuscitation and with available coagulation profile were analyzed. Coagulopathy was defined as international normalized ratio [INR] >1.3, platelet count <100,000 /μL, or partial thromboplastin time >37 sec. Median age (interquartile range; IQR) of our cohort was 27 (21-35) years, and 74 (83%) were male. The intent was assault in 74 cases (83%). The mechanism of PBI was gunshot wound in all patients. Forty patients (45%) were coagulopathic at presentation. In a multiple regression model, coagulopathy was associated with lower Glasgow Coma Scale (GCS)-Motor score (odds ratio [OR], 0.67; confidence interval [CI], 0.48-0.94; p = 0.02) and transfusion of blood products (OR, 3.91; CI, 1.2-12.5; p = 0.02). Effacement of basal cisterns was the only significant radiographical features associated with coagulopathy (OR, 3.34; CI, 1.08-10.37; p = 0.04). Mortality was found to be significantly more common in coagulopathic patients (73% vs. 25%; p < 0.001). However, in our limited sample, reversal of coagulopathy at 24 h was not associated with a statistically significant improvement in outcome. The triad of coagulopathy, low post-resuscitation GCS, and radiographical effacement of basal cisterns identify a particularly ominous phenotype of PBI. The role, and potential reversal of, coagulopathy in this group warrants further investigation.
Collapse
Affiliation(s)
- Ali Mansour
- Neurosciences Intensive Care Unit, Department of Neurology, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.,Section of Neurosurgery, Department of Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Andrea Loggini
- Neurosciences Intensive Care Unit, Department of Neurology, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Fernando D Goldenberg
- Neurosciences Intensive Care Unit, Department of Neurology, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.,Section of Neurosurgery, Department of Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Christopher Kramer
- Neurosciences Intensive Care Unit, Department of Neurology, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.,Section of Neurosurgery, Department of Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Andrew M Naidech
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Evanston, Illinois, USA
| | - Faten El Ammar
- Neurosciences Intensive Care Unit, Department of Neurology, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Valentina Vasenina
- Section of Neurosurgery, Department of Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Brandyn Castro
- Section of Neurosurgery, Department of Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Paramita Das
- Section of Neurosurgery, Department of Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Peleg M Horowitz
- Section of Neurosurgery, Department of Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Theodore Karrison
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Tanya Zakrison
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Evanston, Illinois, USA
| | - David Hampton
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Evanston, Illinois, USA
| | - Selwyn O Rogers
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Evanston, Illinois, USA
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.,Section of Neurosurgery, Department of Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| |
Collapse
|
42
|
Loggini A, Ammar FE, Awad IA, Lazaridis C, Kramer CL, Kordeck C, McKoy C, Goldenberg FD, Mansour A. Temporal Evolution and Outcomes of Non-Traumatic Intracerebral Hemorrhage in Hospitalized Patients. J Stroke Cerebrovasc Dis 2021; 30:105584. [PMID: 33412398 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105584] [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] [Received: 10/22/2020] [Revised: 12/21/2020] [Accepted: 12/25/2020] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To investigate the radiographic features, temporal evolution, and outcome of patients who develop non-traumatic intracerebral hemorrhage (ICH) while hospitalized for other causes. METHODS We retrospectively reviewed consecutive Emergency Department ICH (ED-ICH) and in-hospital ICH (IH-ICH) over an 8-year period. Variables including demographics, medical history, lab values, lead time to diagnosis, defined as time from last known well to first CT scan, and clinical characteristics, follow-up CT scan, as well as the frequency of withdrawal of life support were compared in the two groups. Mortality in correlation with ICH score was assessed. RESULTS Sixty-One IH-ICH and 216 ED-ICH patients were compared. History of cardiac disease, cancer, coagulopathy and higher SOFA score at time of diagnosis were significantly higher in the IH-ICH group (all P< 0.01). Time from symptom onset to diagnosis was shorter in the IH-ICH group (median 95 versus 117 minutes, P=0.011). Thirty six percent of IH-ICH fell into a worse ICH category when recalculated 6 hours from initial scan time, compared to only 10% of the ED-ICH. ICH score was well calibrated in ED-ICH when assessed both at diagnosis and 6 hours later, but underestimated actual mortality in the IH-ICH, particularly at ICH scores 0 to 3. End of life measures were pursued in 69% of IH-ICH group compared to 19% in the ED-ICH group. CONCLUSIONS IH-ICH, is associated with higher overall mortality rates and often times heralds withdrawal of life sustaining therapies in patients. In addition, IH-ICH in comparison to ED-ICH, significantly changes in severity metrics within the first 6 hours. ICH score is not accurate and not calibrated to reflect reasonable stratification of mortality in IH-ICH. Prospective validation and investigation of variables accounting for higher IH-ICH mortality are needed.
Collapse
Affiliation(s)
- Andrea Loggini
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL 60637-1470, USA.
| | - Faten El Ammar
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL 60637-1470, USA.
| | - Issam A Awad
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL 60637-1470, USA; Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christopher L Kramer
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL 60637-1470, USA; Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christi Kordeck
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL 60637-1470, USA.
| | - Cedric McKoy
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL 60637-1470, USA.
| | - Fernando D Goldenberg
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL 60637-1470, USA; Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Ali Mansour
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., MC 2030, Chicago, IL 60637-1470, USA; Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| |
Collapse
|
43
|
Lazaridis C. Defining Death: Reasonableness and Legitimacy. J Clin Ethics 2021; 32:109-113. [PMID: 34129526] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The recently published World Brain Death Project aims in alleviating inconsistencies in clinical guidelines and practice in the determination of death by neurologic criteria. However, critics have taken issue with a number of epistemic and metaphysical assertions that critics argue are either false, ad hoc, or confused. In this commentary, I discuss the nature of a definition of death; the plausibility of neurologic criteria as a sensible social, medical, and legal policy; and within a Rawlsian liberal framework, reasons for personal choice or accommodation among neurologic and circulatory definitions. Declaration of human death cannot rest on contested metaphysics or unmeasurable standards, instead it should be regarded as a plausible and widely accepted social construct that conforms to best available and pragmatic medical science and practice. The definition(s) and criteria should be transparent, publicly justifiable, and potentially allow for the accommodation of reasonable choice. This is an approach that situates the definition of death as a political matter. The approach anticipates that no conceptualization of death can claim universal validity, since this is a question that cannot be settled solely on biologic or scientific grounds, rather it is a matter of normative preference, socially constructed and historically contingent.
Collapse
Affiliation(s)
- Christos Lazaridis
- Neurocritical Care, Departments of Neurology/Neurosurgery, MacLean Center for Clinical Ethics, University of Chicago, 5841 S. Maryland Ave|MC 2030, Chicago, Illinois 60637 USA.
| |
Collapse
|
44
|
Loggini A, Tangonan R, El Ammar F, Mansour A, Kramer CL, Lazaridis C, Goldenberg FD. Neuroendocrine Dysfunction in the Acute Setting of Penetrating Brain Injury: A Systematic Review. World Neurosurg 2020; 147:172-180.e1. [PMID: 33346052 DOI: 10.1016/j.wneu.2020.12.058] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Data on neuroendocrine dysfunction (NED) in the acute setting of penetrating brain injury (PBI) are scarce, and the clinical approach to diagnosis and treatment remains extrapolated from the literature on blunt head trauma. METHODS Three databases were searched (PubMed, Scopus, and Cochrane). Risk of bias was computed using the Newcastle-Ottawa Scale, or the methodological quality of case series and case reports, as indicated. This systematic review was registered in PROSPERO (42020172163). RESULTS Six relevant studies involving 58 patients with PBI were included. Two studies were prospective cohort analyses, whereas 4 were case reports. The onset of NED was acute in all studies, by the first postinjury day. Risk factors for NED included worse injury severity and the presence of cerebral edema on imaging. Dysfunction of the anterior hypophysis involved the hypothalamic-pituitary-thyroid axis, treated with hormonal replacement, and hypocortisolism, treated with hydrocortisone. The prevalence of central diabetes insipidus was up to 41%. Most patients showed persistent NED months after injury. In separate reports, diabetes insipidus and hypocortisolism showed an association with higher mortality. The available literature for this review is poor, and the studies included had overall low quality with high risk of bias. CONCLUSIONS NED seems to be prevalent in the acute phase of PBI, equally involving both anterior and posterior hypophysis. Despite a potential association between NED and mortality, data on the optimal management of NED are limited. This situation defines the need for prospective studies to better characterize the clinical features and optimal therapeutic interventions for NED in PBI.
Collapse
Affiliation(s)
- Andrea Loggini
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA.
| | - Ruth Tangonan
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Faten El Ammar
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Ali Mansour
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Christopher L Kramer
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Christos Lazaridis
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Fernando D Goldenberg
- Neuroscience Intensive Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, Illinois, USA
| |
Collapse
|
45
|
Godoy DA, Rovegno M, Lazaridis C, Badenes R. The effects of arterial CO 2 on the injured brain: Two faces of the same coin. J Crit Care 2020; 61:207-215. [PMID: 33186827 DOI: 10.1016/j.jcrc.2020.10.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/08/2020] [Accepted: 10/29/2020] [Indexed: 01/14/2023]
Abstract
Serum levels of carbon dioxide (CO2) closely regulate cerebral blood flow (CBF) and actively participate in different aspects of brain physiology such as hemodynamics, oxygenation, and metabolism. Fluctuations in the partial pressure of arterial CO2 (PaCO2) modify the aforementioned variables, and at the same time influence physiologic parameters in organs such as the lungs, heart, kidneys, and the gastrointestinal tract. In general, during acute brain injury (ABI), maintaining normal PaCO2 is the target to be achieved. Both hypercapnia and hypocapnia may comprise secondary insults and should be avoided during ABI. The risks of hypocapnia mostly outweigh the potential benefits. Therefore, its therapeutic applicability is limited to transient and second-stage control of intracranial hypertension. On the other hand, inducing hypercapnia could be beneficial when certain specific situations require increasing CBF. The evidence supporting this claim is very weak. This review attempts providing an update on the physiology of CO2, its risks, benefits, and potential utility in the neurocritical care setting.
Collapse
Affiliation(s)
- Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina; Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina.
| | - Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Christos Lazaridis
- Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Rafael Badenes
- Anesthesiology and Surgical-Trauma Intensive Care, University Clinic Hospital, Valencia, Spain,; Department of Surgery, University of Valencia, Spain; INCLIVA Research Medical Institute, Valencia, Spain
| |
Collapse
|
46
|
Loggini A, El Ammar F, Mansour A, Kramer CL, Goldenberg FD, Lazaridis C. Association between electrolyte levels at presentation and hematoma expansion and outcome in spontaneous intracerebral hemorrhage: A systematic review. J Crit Care 2020; 61:177-185. [PMID: 33181414 DOI: 10.1016/j.jcrc.2020.10.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 06/30/2020] [Revised: 08/31/2020] [Accepted: 10/29/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To assess the association between specific electrolyte levels (sodium, potassium, calcium, magnesium, and phosphorus) on presentation and hematoma expansion (HE) and outcome in intracerebral hemorrhage (ICH). METHODS This review was conducted in accordance with the PRISMA statement recommendations. Three databases were searched (Pubmed, Scopus, and Cochrane). Risk of bias was computed using the Newcastle-Ottawa Scale tool. RESULTS 18 full-text articles were included in this systematic review including 10,385 ICH patients. Hypocalcemia was associated with worse short-term outcome in four studies, and two other studies were neutral. All studies investigating HE in hypocalcemia (n = 5) reported an association between low calcium level and HE. Hyponatremia (Na < 135 mEq/L) was shown to correlate with worse short-term outcome in two studies, and worse long-term outcome in one. There was one report showing no association between sodium level and HE. Hypomagnesemia was shown to be associated with worse short-term outcome in one study, while other reports were neutral. Studies evaluating hypophosphatemia or hypokalemia in ICH were limited, with no demonstrable significant effect on outcome. CONCLUSION This review suggests a significant association between hypocalcemia, hyponatremia and, of lesser degree, hypomagnesemia on admission and HE or worse outcome in ICH.
Collapse
Affiliation(s)
- Andrea Loggini
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States.
| | - Faten El Ammar
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Ali Mansour
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Christopher L Kramer
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Fernando D Goldenberg
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Christos Lazaridis
- Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| |
Collapse
|
47
|
Sotiriadou M, Antoniadis A, Vergopoulos S, Lazaridis C, Konstantinidis P, Bakogiannis C, Virgiliou C, Gkika E, Theodoridis G, Mpalaouri I, Mpougiouklis D, Gerou S, Papadopoulos C, Fragakis N, Vassilikos V. Baseline adenosine plasma levels indicate differential response to adenosine test and head-up tilt test in syncopal patients. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background/Introduction
Head-up tilt table test (HUTT) and Adenosine test (ADT) can be useful in the diagnostic evaluation of syncope. Adenosine plasma (ADP) and Adenosine receptor (ADR) levels may differentiate the outcomes of HUTT and ADT but their precise role in the risk stratification of patients with syncope remains elusive.
Purpose
We sought to assess the ADP and ADR levels in patients without structural heart disease who underwent HUTT and ADT tests as part of the diagnostic workup of syncope. We specifically investigated differences in the outcomes of the HUTT and ADT tests as well as to the ADP levels during HUTT according to the baseline ADP levels.
Methods
HUTT and ADT were performed as per the standard protocols. ADT was considered positive in the event of asystole >6 seconds or heart block for >10 seconds after intravenous Adenosine 0.15 mg/kg administration in the supine position. ADP levels (ppm/Um/L) were assessed at three timepoints during the HUTT: at baseline (supine), immediately after bed tilt and, in cases of a positive HUTT, at the time of syncope. Patients were categorized in terciles of low, intermediate and high baseline ADP levels. We also assessed the A2A ADR levels of monocytes.
Results
We prospectively analyzed 106 patients (62 women, age 46.87±20.63 years). ADT was positive in 14.2% of patients and HUTT in 47.2% of patients. Females were more likely to have low ADP levels (odds ratio [OR] 2.70, 95% Confidence Interval [CI] 1.04 to 6.94, p<0.05). Patients with low baseline ADP levels showed a trend for positive ADT (OR 3.15, 95% CI 1.05 to 10.85, p=0.07), while patients with high baseline ADP levels showed a trend for negative HUTT (OR 2.35, 95% CI 0.94 to 5.90, p=0.075). Within patients with positive HUTT, those with low baseline ADP levels, showed an increase in ADP in the tilt phase (0.063 vs 0.027 ppm/Um/L, p<0.05) but not at the time of syncope (0.045 ppm/Um/L) while those with intermediate baseline ADP levels showed an increase in ADP in the tilt phase (0.16 vs 0.095 ppm/Um/L, p<0.05) which persisted during syncope (0.18 ppm/Um/L, p<0.05). Patients with high baseline ADP levels did not exhibit differences in ADP during positive HUTT. Higher baseline ADP levels were associated with smaller increases in the tilt phase (Pearson's r −0.621, p<0.001). ADR levels in patients with positive HUTT correlated positively with baseline ADP levels (Pearson's r 0.878, p<0.001).
Conclusion(s)
Baseline ADP levels may be related to the outcome of ADT and HUTT. ADP increases during HUTT except for patients with high baseline ADP. ADP and ADR levels warrant further investigation as they may characterize a subset of patients with specific responses to HUTT and may be implicated in the pathophysiology of reflex syncope.
Funding Acknowledgement
Type of funding source: None
Collapse
Affiliation(s)
- M Sotiriadou
- Hippocration General Hospital, Aristotle University Medical School, 3rd Department of Cardiology, Thessaloniki, Greece
| | - A Antoniadis
- Hippocration General Hospital, Aristotle University Medical School, 3rd Department of Cardiology, Thessaloniki, Greece
| | - S Vergopoulos
- General Hospital of Chalkidiki, Department of Internal Medicine, Polygyros, Greece
| | - C Lazaridis
- Hippocration General Hospital, Aristotle University Medical School, 3rd Department of Cardiology, Thessaloniki, Greece
| | - P Konstantinidis
- Hippocration General Hospital, Aristotle University Medical School, 3rd Department of Cardiology, Thessaloniki, Greece
| | - C Bakogiannis
- Hippocration General Hospital, Aristotle University Medical School, 3rd Department of Cardiology, Thessaloniki, Greece
| | - C Virgiliou
- Aristotle University of Thessaloniki, Department of Chemistry, Thessaloniki, Greece
| | - E Gkika
- Aristotle University of Thessaloniki, Laboratory of Forensic Medicine and Toxicology, School of Medicine, Thessaloniki, Greece
| | - G Theodoridis
- Aristotle University of Thessaloniki, Department of Chemistry, Thessaloniki, Greece
| | - I Mpalaouri
- Analysi Iatriki A.E. Diagnostic - Research Clinics, Thessaloniki, Greece
| | - D Mpougiouklis
- Analysi Iatriki A.E. Diagnostic - Research Clinics, Thessaloniki, Greece
| | - S Gerou
- Analysi Iatriki A.E. Diagnostic - Research Clinics, Thessaloniki, Greece
| | - C Papadopoulos
- Hippocration General Hospital, Aristotle University Medical School, 3rd Department of Cardiology, Thessaloniki, Greece
| | - N Fragakis
- Hippocration General Hospital, Aristotle University Medical School, 3rd Department of Cardiology, Thessaloniki, Greece
| | - V Vassilikos
- Hippocration General Hospital, Aristotle University Medical School, 3rd Department of Cardiology, Thessaloniki, Greece
| |
Collapse
|
48
|
Mansour A, Loggini A, El Ammar F, Ginat D, Awad IA, Lazaridis C, Kramer C, Vasenina V, Polster SP, Huang A, Olivera Perez H, Das P, Horowitz PM, Zakrison T, Hampton D, Rogers SO, Goldenberg FD. Cerebrovascular Complications in Early Survivors of Civilian Penetrating Brain Injury. Neurocrit Care 2020; 34:918-926. [PMID: 33025542 PMCID: PMC9159343 DOI: 10.1007/s12028-020-01106-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 07/14/2020] [Accepted: 09/03/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome. METHODS We retrospectively reviewed patients with PBI admitted to our institution over a 2-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome. RESULTS Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model, intraventricular hemorrhage at presentation was associated with AI (OR 9.9, p = 0.004). The same was not true for VSI. CONCLUSION Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.
Collapse
Affiliation(s)
- Ali Mansour
- Neurosciences Intensive Care Unit, Neurocritical Care, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave, MC 2030, Chicago, IL, 60637-1470, USA.
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Andrea Loggini
- Neurosciences Intensive Care Unit, Neurocritical Care, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave, MC 2030, Chicago, IL, 60637-1470, USA
| | - Faten El Ammar
- Neurosciences Intensive Care Unit, Neurocritical Care, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave, MC 2030, Chicago, IL, 60637-1470, USA
| | - Daniel Ginat
- Section of Neuroradiology, Department of Radiology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Issam A Awad
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Neurocritical Care, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave, MC 2030, Chicago, IL, 60637-1470, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Christopher Kramer
- Neurosciences Intensive Care Unit, Neurocritical Care, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave, MC 2030, Chicago, IL, 60637-1470, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Valentina Vasenina
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Sean P Polster
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Anna Huang
- Pritzker School of Medicine, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Henry Olivera Perez
- Pritzker School of Medicine, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Paramita Das
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Peleg M Horowitz
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Tanya Zakrison
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - David Hampton
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Selwyn O Rogers
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Fernando D Goldenberg
- Neurosciences Intensive Care Unit, Neurocritical Care, Department of Neurology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave, MC 2030, Chicago, IL, 60637-1470, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| |
Collapse
|
49
|
Abstract
A challenging clinical conundrum arises in severe traumatic brain injury patients who develop intractable intracranial hypertension. For these patients, high morbidity interventions such as surgical decompression and barbiturate coma have to be considered against a backdrop of uncertain outcomes including prolonged states of disordered consciousness and severe disability. The clinical evidence available to guide shared decision-making is mainly limited to one randomized controlled trial, the RESCUEicp. However, since the publication of this trial significant controversy has been ongoing over the interpretation of the results. Is the mortality benefit from surgery merely a trade off for unacceptable long-term disability? How should treatment options, possible outcomes, and results from the trial be communicated to surrogates? How do we incorporate patient values into forming plans of care? The aim of this article is to sketch an approach based on insights from Decision Theory, and specifically deciding under uncertainty. The mainstream normative decision theory, Expected Utility (EU) theory, essentially says that, in situations of uncertainty, one should prefer the option with greatest expected desirability or value. The steps required to compute expected utilities include listing the possible outcomes of available interventions, assigning each outcome a utility ranking representing an individual patient's preferences, and a conditional probability given each intervention. This is a conceptual framework meant to supplement, and enhance shared decision making by assuring that patient values are elicited and incorporated, the possible range and nature of outcomes is discussed, and finally by attempting to connect best available means to patient-individualized ends.
Collapse
Affiliation(s)
- Christos Lazaridis
- Neurocritical Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, IL, United States.,Section of Neurosurgery, Department of Surgery, University of Chicago Medical Center, Chicago, IL, United States
| |
Collapse
|
50
|
Trifan G, Goldenberg FD, Caprio FZ, Biller J, Schneck M, Khaja A, Terna T, Brorson J, Lazaridis C, Bulwa Z, Alvarado Dyer R, Saleh Velez FG, Prabhakaran S, Liotta EM, Batra A, Reish NJ, Ruland S, Teitcher M, Taylor W, De la Pena P, Conners JJ, Grewal PK, Pinna P, Dafer RM, Osteraas ND, DaSilva I, Hall JP, John S, Shafi N, Miller K, Moustafa B, Vargas A, Gorelick PB, Testai FD. Characteristics of a Diverse Cohort of Stroke Patients with SARS-CoV-2 and Outcome by Sex. J Stroke Cerebrovasc Dis 2020; 29:105314. [PMID: 32951959 PMCID: PMC7486061 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105314] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/03/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022] Open
Abstract
COVID-19 disease is associated with stroke All strokes subtypes are seen in association with COVID-19, with ischemic stroke being most prevalent The most common etiology for ischemic stroke in SARS-CoV2 infection is cryptogenic Sex plays an important role in stroke outcomes in patients with COVID-19 disease Males have higher rates of ICU admission, in-hospital complications and more likely to have worse outcome at hospital discharge compare with females
Background and Purpose Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. To objective of this paper is to describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease and determine the role of sex on outcome. Methods This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage or median and interquartile range. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. Results The study included 83 patients, 47% of which were Black, 28% Hispanics/Latinos, and 16% whites. Median age was 64 years. Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Compared with females, a higher proportion of males experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%; p = 0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%). Compared with females, males had higher mortality (38% vs. 13%; p = 0.02) and were less likely to be discharged home (12% vs. 33%; p = 0.04). After adjustment for age, race/ethnicity, and number of VRFs, mRS was higher in males than in females (OR = 1.47, 95% CI = 1.03–2.09). Conclusion In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence of coronavirus infection on admission and preexisting VRFs. Severe in-hospital complications and worse outcomes after ischemic strokes were higher in males, than females.
Collapse
Affiliation(s)
- G Trifan
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL 60612, U.S.A..
| | - F D Goldenberg
- Department of Neurology, University of Chicago Hospital, Chicago, IL 60612, U.S.A..
| | - F Z Caprio
- Department of Neurology, Northwestern University, 633 Clark St, Evanston, IL 60208, U.S.A..
| | - J Biller
- Department of Neurology, Loyola University Health System, 2160 S 1st Ave, Maywood, IL 60153, U.S.A..
| | - M Schneck
- Department of Neurology, Loyola University Health System, 2160 S 1st Ave, Maywood, IL 60153, U.S.A..
| | - A Khaja
- AMITA Health - Alexian Brothers Hospital, 800 Biesterfield Rd, IL 60007, U.S.A..
| | - T Terna
- AMITA Health - Alexian Brothers Hospital, 800 Biesterfield Rd, IL 60007, U.S.A..
| | - J Brorson
- Department of Neurology, University of Chicago Hospital, Chicago, IL 60612, U.S.A
| | - C Lazaridis
- Department of Neurology, University of Chicago Hospital, Chicago, IL 60612, U.S.A..
| | - Z Bulwa
- Department of Neurology, University of Chicago Hospital, Chicago, IL 60612, U.S.A..
| | - R Alvarado Dyer
- Department of Neurology, University of Chicago Hospital, Chicago, IL 60612, U.S.A..
| | - F G Saleh Velez
- Department of Neurology, University of Chicago Hospital, Chicago, IL 60612, U.S.A..
| | - S Prabhakaran
- Department of Neurology, University of Chicago Hospital, Chicago, IL 60612, U.S.A..
| | - E M Liotta
- Department of Neurology, Northwestern University, 633 Clark St, Evanston, IL 60208, U.S.A..
| | - A Batra
- Department of Neurology, Northwestern University, 633 Clark St, Evanston, IL 60208, U.S.A..
| | - N J Reish
- Department of Neurology, Northwestern University, 633 Clark St, Evanston, IL 60208, U.S.A..
| | - S Ruland
- Department of Neurology, Loyola University Health System, 2160 S 1st Ave, Maywood, IL 60153, U.S.A..
| | - M Teitcher
- Department of Neurology, Loyola University Health System, 2160 S 1st Ave, Maywood, IL 60153, U.S.A..
| | - W Taylor
- Department of Neurology, Loyola University Health System, 2160 S 1st Ave, Maywood, IL 60153, U.S.A..
| | - P De la Pena
- Department of Neurology, Loyola University Health System, 2160 S 1st Ave, Maywood, IL 60153, U.S.A..
| | - J J Conners
- Department of Neurological Sciences, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, U.S.A..
| | - P K Grewal
- Department of Neurological Sciences, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, U.S.A..
| | - P Pinna
- Department of Neurological Sciences, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, U.S.A..
| | - R M Dafer
- Department of Neurological Sciences, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, U.S.A..
| | - N D Osteraas
- Department of Neurological Sciences, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, U.S.A..
| | - I DaSilva
- Department of Neurological Sciences, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, U.S.A..
| | - J P Hall
- Department of Neurological Sciences, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, U.S.A..
| | - S John
- Department of Neurological Sciences, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, U.S.A..
| | - N Shafi
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL 60612, U.S.A..
| | - K Miller
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL 60612, U.S.A..
| | - B Moustafa
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL 60612, U.S.A..
| | - A Vargas
- Department of Neurological Sciences, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, U.S.A..
| | - P B Gorelick
- Department of Neurology, Northwestern University, 633 Clark St, Evanston, IL 60208, U.S.A..
| | - F D Testai
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL 60612, U.S.A..
| |
Collapse
|