The incidence of neurological complications in mechanically ventilated COVID-19 ICU patients: An observational single-center cohort study in three COVID-19 periods

BACKGROUND

Neurological complications in COVID-19 patients admitted to an intensive care unit (ICU) have been previously reported. As the pandemic progressed, therapeutic strategies were tailored to new insights. This study describes the incidence, outcome, and types of reported neurological complications in invasively mechanically ventilated (IMV) COVID-19 patients in relation to three periods during the pandemic.

METHODS

IMV COVID-19 ICU patients from the Dutch Maastricht Intensive Care COVID (MaastrICCht) cohort were included in a single-center study (March 2020 - October 2021). Demographic, clinical, and follow-up data were collected. Electronic medical records were screened for neurological complications during hospitalization. Three distinct periods (P1, P2, P3) were defined, corresponding to periods with high hospitalization rates. ICU survivors with and without reported neurological complications were compared in an exploratory analysis.

RESULTS

IMV COVID-19 ICU patients (n=324; median age 64 [IQR 57-72] years; 238 males (73.5%)) were stratified into P1 (n=94), P2 (n=138), and P3 (n=92). ICU mortality did not significantly change over time (P1=38.3%; P2=41.3%; P3=37.0%; p=.787). The incidence of reported neurological complications during ICU admission gradually decreased over the periods (P1=29.8%; P2=24.6%; P3=18.5%; p=.028). Encephalopathy/delirium (48/324 (14.8%)) and ICU-acquired weakness (32/324 (9.9%)) were most frequently reported and associated with ICU treatment intensity. ICU survivors with neurological complications (n=53) were older (p=.025), predominantly male (p=.037), and had a longer duration of IMV (p<.001) and ICU stay (p<.001), compared to survivors without neurological complications (n=132). A multivariable analysis revealed that only age was independently associated with the occurrence of neurological complications (ORadj=1.0541; 95% CI=1.0171-1.0925; p=.004). Health-related quality-of-life at follow-up was not significantly different between survivors with and without neurological complications (n = 82, p=.054).

CONCLUSIONS

A high but decreasing incidence of neurological complications was reported during three consecutive COVID-19 periods in IMV COVID-19 patients. Neurological complications were related to the intensity of ICU support and treatment, and associated with prolonged ICU stay, but did not lead to significantly worse reported health-related quality-of-life at follow-up.

On the merits and potential of advanced neuroimaging techniques in COVID-19: A scoping review

Many Coronavirus Disease 2019 (COVID-19) patients are suffering from long-term neuropsychological sequelae. These patients may benefit from a better understanding of the underlying neuropathophysiological mechanisms and identification of potential biomarkers and treatment targets. Structural clinical neuroimaging techniques have limited ability to visualize subtle cerebral abnormalities and to investigate brain function. This scoping review assesses the merits and potential of advanced neuroimaging techniques in COVID-19 using literature including advanced neuroimaging or postmortem analyses in adult COVID-19 patients published from the start of the pandemic until December 2023. Findings were summarized according to distinct categories of reported cerebral abnormalities revealed by different imaging techniques. Although no unified COVID-19-specific pattern could be subtracted, a broad range of cerebral abnormalities were revealed by advanced neuroimaging (likely attributable to hypoxic, vascular, and inflammatory pathology), even in absence of structural clinical imaging findings. These abnormalities are validated by postmortem examinations. This scoping review emphasizes the added value of advanced neuroimaging compared to structural clinical imaging and highlights implications for brain functioning and long-term consequences in COVID-19.

Long-Term Follow-Up of Critically Ill Patients With Traumatic Brain Injury: From Intensive Care Parameters to Patient and Caregiver-Reported Outcome

Abstract Traumatic brain injury (TBI) is associated with a high social and financial burden due to persisting (severe) disabilities. The consequences of TBI after intensive care unit (ICU) admission are generally measured with global disability screeners such as the Glasgow Outcome Scale-Extended (GOSE), which may lack precision. To improve outcome measurement after brain injury, a comprehensive clinical outcome assessment tool called the Minimal Dataset for Acquired Brain Injury (MDS-ABI) was recently developed. The MDS-ABI covers 12 life domains (demographics, injury characteristics, comorbidity, cognitive functioning, emotional functioning, energy, mobility, self-care, communication, participation, social support, and quality of life), as well as informal caregiver capacity and strain. In this cross-sectional study, we used the MDS-ABI among formerly ICU admitted patients with TBI to explore the relationship between dichotomized severity of TBI and long-term outcome. Our objectives were to: 1) summarize demographics, clinical characteristics, and long-term outcomes of patients and their informal caregivers, and 2) compare differences between long-term outcomes in patients with mild-moderate TBI and severe TBI based on Glasgow Coma Scale (GCS) scores at admission. Participants were former patients of a Dutch university hospital (total n = 52; mild-moderate TBI n = 23; severe TBI n = 29) and their informal caregivers (n = 45). Hospital records were evaluated, and the MDS-ABI was administered during a home visit. On average 3.2 years after their TBI, 62% of the patients were cognitively impaired, 62% reported elevated fatigue, and 69% experienced restrictions in ≥2 participation domains (most frequently work or education and going out). Informal caregivers generally felt competent to provide necessary care (81%), but 31% experienced a disproportionate caregiver burden. All but four patients lived at home independently, often together with their informal caregiver (81%). Although the mild-moderate TBI group and the severe TBI group had significantly different clinical trajectories, there were no persisting differences between the groups for patient or caregiver outcomes at follow-up. As a large proportion of the patients experienced long-lasting consequences beyond global disability or independent living, clinicians should implement a multi-domain outcome set such as the MDS-AB to follow up on their patients.

The dependence of cerebral interstitial fluid on diffusion-sensitizing directions: A multi-b-value diffusion MRI study in a memory clinic sample

Three-component intravoxel incoherent motion (3C-IVIM) imaging with spectral analysis provides a proxy for interstitial fluid (ISF) (e.g., in perivascular spaces (PVS), granting a potential marker for altered cerebral clearance. When 3C-IVIM images are acquired with three orthogonal diffusion-sensitizing directions, these are often averaged into the Trace image. This may result in loss of valuable direction-specific information, particularly in PVS-rich regions (basal ganglia (BG) and centrum semiovale (CSO)). This study assessed the dependence of individual diffusion-sensitizing directions to the ISF fraction in PVS-rich regions. Additionally, we explored the value of diffusion direction-specific information on ISF characteristics in distinguishing thirty-one patients with cognitive impairment (CI) (Alzheimer's disease (n = 15) or Mild Cognitive Impairment (n = 16)) from thirty cognitively healthy elderly controls (CON). Multi-b-value diffusion-weighted images were acquired in three orthogonal directions (L-R (left-right), A-P (anterior-posterior) and S-I (superior-inferior)) at 3 T. Voxel-based spectral analysis using non-negative least squares was conducted to independently analyze the L-R, A-P, S-I, and Trace images. 3C-IVIM measures were first compared between diffusion-sensitizing directions and the Trace within the BG using repeated measures ANOVA. Subsequently, the 3C-IVIM measures were compared per direction between the CI and CSO group in the BG and CSO with multivariable linear regression. Our results show that the ISF fraction significantly differs between all diffusion-sensitizing directions and Trace in the BG, with the highest ISF fraction detected using S-I. Solely using S-I, a higher ISF fraction was identified in CI compared to CON in the BG (p = .020) and CSO (p = .046). Thereby, this study found that the measured ISF fraction depends on the acquired diffusion-sensitizing direction, where S-I is most sensitive to detect ISF and differences between CI and CON. The Trace approach is not always sensitive enough to ISF characteristics. Solely acquiring S-I may offer an alternative to reduce scanning time.

[Clinical course of COVID-19 in the Netherlands: an overview of 2607 patients in hospital during the first wave]

OBJECTIVE

To systematically collect clinical data from patients with a proven COVID-19 infection in the Netherlands.

DESIGN

Data from 2579 patients with COVID-19 admitted to 10 Dutch centers in the period February to July 2020 are described. The clinical data are based on the WHO COVID case record form (CRF) and supplemented with patient characteristics of which recently an association disease severity has been reported.

METHODS

Survival analyses were performed as primary statistical analysis. These Kaplan-Meier curves for time to (early) death (3 weeks) have been determined for pre-morbid patient characteristics and clinical, radiological and laboratory data at hospital admission.

RESULTS

Total in-hospital mortality after 3 weeks was 22.2% (95% CI: 20.7% - 23.9%), hospital mortality within 21 days was significantly higher for elderly patients (> 70 years; 35, 0% (95% CI: 32.4% - 37.8%) and patients who died during the 21 days and were admitted to the intensive care (36.5% (95% CI: 32.1% - 41.3%)). Apart from that, in this Dutch population we also see a risk of early death in patients with co-morbidities (such as chronic neurological, nephrological and cardiac disorders and hypertension), and in patients with more home medication and / or with increased urea and creatinine levels.

CONCLUSION

Early death due to a COVID-19 infection in the Netherlands appears to be associated with demographic variables (e.g. age), comorbidity (e.g. cardiovascular disease) but also disease char-acteristics at admission.

Cerebral and Limb Tissue Oxygenation During Peripheral Venoarterial Extracorporeal Life Support

Femoral access in extracorporeal life support (ECLS) has been associated with regional variations in arterial oxygen saturation, potentially predisposing the patient to ischemic tissue damage. Current monitoring techniques, however, are limited to intermittent bedside evaluation of capillary refill among other factors. The aim of this study was to assess whether cerebral and limb regional tissue oxygen saturation (rSO₂) values reflect changes in various patient-related parameters during venoarterial ECLS (VA-ECLS). This retrospective observational study included adults assisted by femorofemoral VA-ECLS. Bifrontal cerebral and bilateral limb tissue oximetry was performed for the entire duration of support. Hemodynamic data were analyzed parallel to cerebral and limb rSO₂. A total of 23 patients were included with a median ECLS duration of 5 [1-20] days. Cardiac arrhythmias were observed in 12 patients, which was associated with a decreased mean rSO₂ from 61%±11% to 51%±10% during atrial fibrillation and 67%±9% to 58%±10% during ventricular fibrillation (P<0.001 for both). A presumably sudden increase in cardiac output due to myocardial recovery (n=8) resulted in a significant decrease in mean cerebral rSO₂ from 73%±7% to 54%±6% and from 69%±9% to 53%±8% for the left and right cerebral hemisphere, respectively (P=0.012 for both hemispheres). Also, right radial artery partial gas pressure for oxygen decreased from 15.6±2.8 to 8.3±1.9 kPa (P=0.028). No differences were found in cerebral desaturation episodes between patients with and without neurologic complications. In six patients, limb rSO₂ increased from on average 29.3±2.7 to 64.0±5.1 following insertion of a distal cannula in the femoral artery (P=0.027). Likewise, restoration of flow in a clotted distal cannula inserted in the femoral artery was necessary in four cases and resulted in increased limb rSO₂ from 31.3±0.8 to 79.5±9.0; P=0.068. Non-invasive tissue oximetry adequately reflects events influencing cerebral and limb perfusion and can aid in monitoring tissue perfusion in patients assisted by ECLS.

[A woman with a seat belt sign after a car accident]

A 48-year-old woman presented with a cervicothoracic seat belt sign after a car accident as a front seat passenger. The CT scan showed right common carotid artery dissection with a pseudoaneurysm, a right clavicle fracture, sternal fracture, multiple rib fractures left and a laceration of the spleen. She did not develop any neurologic deficits.

tPA treatment for acute ischaemic stroke in patients with leukoaraiosis

BACKGROUND AND PURPOSE

Whether leukoaraiosis on baseline CT is associated with an increased risk of symptomatic intracerebral haemorrhage (sICH) or poor outcome following tissue plasminogen activator (tPA) treatment for acute ischaemic stroke is still a matter of debate.

OBJECTIVE

To investigate the relationship between the presence and severity of leukoaraiosis on baseline CT and the risk of sICH and functional outcome after tPA treatment for acute ischaemic stroke.

METHODS

A single-center observational cohort study with a retrospective analysis on consecutive patients with ischaemic stroke treated with tPA in the period 2002-2008. Outcome measures were the occurrence of sICH and functional outcome at 3 months.

RESULTS

Of the 400 patients, 24% had leukoaraiosis on their baseline CT. Eleven patients (11%) with leukoaraiosis versus thirteen (4%) patients without leukoaraiosis had a sICH [odds ratio (OR) 2.85 95%-CI 1.23-6.60, P = 0.02]. Multivariate analysis showed a non-significant trend towards an association of leukoaraiosis and sICH (OR 1.9, 95%-CI 0.78-4.68, P = 0.16). Leukoaraiosis was independently associated with poor functional outcome (OR 2.39, 95%-CI 1.21-4.72, P = 0.01). No difference was observed in the outcome measures amongst patients with moderate or severe leukoaraiosis.

CONCLUSION

Our study demonstrates that patients treated with tPA and leukoaraiosis on their baseline CT are at greater risk of sICH and have a worse functional outcome compared to patients without leukoaraiosis. It is important to note that these results should not lead to exclusion of patients with leukoaraiosis for tPA treatment.

The syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis mimicking acute ischemic stroke

Headache with neurologic deficits and cerebrospinal fluid lymphocytosis is a benign condition with a transient ischemic attack-like presentation. We present a case of a 22-year-old man with episodes of right-sided weakness, global dysphasia, and right-sided homonymous hemianopsia associated with frequent vomiting. Systemic thrombolytic therapy was considered. A subsequent magnetic resonance image with diffusion-weighted images revealed normal findings. A diagnosis of headache with neurologic deficits and cerebrospinal fluid lymphocytosis was made based mainly on clinical symptoms and cerebrospinal fluid analysis. With the current pressure on "door-to-needle" time for thrombolysis, it is important to keep an open eye to stroke mimics and exclude them if possible. We, therefore, strongly advise considering noninvasive magnetic resonance diffusion-weighted imaging in patients with unusual presentations (e.g., the vomiting in our patient) before thrombolysis.

Fracture treatment by bonesetters in central Ghana: patients explain their choices and experiences

OBJECTIVE

To understand factors influencing patients' decisions to choose either fracture treatment by a bonesetter or in the hospital and to explore patients' experiences with bonesetter treatment.

METHOD

In-depth interviews with 46 patients with a radiological proven fracture in a district hospital in central Ghana.

RESULTS

Traditional healers, such as bonesetters, play a substantial role in the Ghanaian healthcare system. Over a period of 3 months, 14 patients with a proven fracture left hospital for treatment by a bonesetter. The hospital is considered the only institution where emergency care can be provided and reliable, extensive diagnostic and treatment facilities are available for fracture treatment. Patients opting for bonesetter treatment are guided by the severity of the fracture, availability of the service, their financial status and past experiences. The healing methods used by different bonesetters are based on mutual comparable principles.

CONCLUSION

Fracture treatment can serve as a model for respectful and efficient co-existence of traditional and biomedical medicine.