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Martini ML, Neifert SN, Shuman WH, Chapman EK, Schüpper AJ, Oermann EK, Mocco J, Todd M, Torner JC, Molyneux A, Mayer S, Roux PL, Vergouwen MDI, Rinkel GJE, Wong GKC, Kirkpatrick P, Quinn A, Hänggi D, Etminan N, van den Bergh WM, Jaja BNR, Cusimano M, Schweizer TA, Suarez JI, Fukuda H, Yamagata S, Lo B, Leonardo de Oliveira Manoel A, Boogaarts HD, Macdonald RL. Rescue therapy for vasospasm following aneurysmal subarachnoid hemorrhage: a propensity score-matched analysis with machine learning. J Neurosurg 2021; 136:134-147. [PMID: 34214980 DOI: 10.3171/2020.12.jns203778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rescue therapies have been recommended for patients with angiographic vasospasm (aVSP) and delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). However, there is little evidence from randomized clinical trials that these therapies are safe and effective. The primary aim of this study was to apply game theory-based methods in explainable machine learning (ML) and propensity score matching to determine if rescue therapy was associated with better 3-month outcomes following post-SAH aVSP and DCI. The authors also sought to use these explainable ML methods to identify patient populations that were more likely to receive rescue therapy and factors associated with better outcomes after rescue therapy. METHODS Data for patients with aVSP or DCI after SAH were obtained from 8 clinical trials and 1 observational study in the Subarachnoid Hemorrhage International Trialists repository. Gradient boosting ML models were constructed for each patient to predict the probability of receiving rescue therapy and the 3-month Glasgow Outcome Scale (GOS) score. Favorable outcome was defined as a 3-month GOS score of 4 or 5. Shapley Additive Explanation (SHAP) values were calculated for each patient-derived model to quantify feature importance and interaction effects. Variables with high SHAP importance in predicting rescue therapy administration were used in a propensity score-matched analysis of rescue therapy and 3-month GOS scores. RESULTS The authors identified 1532 patients with aVSP or DCI. Predictive, explainable ML models revealed that aneurysm characteristics and neurological complications, but not admission neurological scores, carried the highest relative importance rankings in predicting whether rescue therapy was administered. Younger age and absence of cerebral ischemia/infarction were invariably linked to better rescue outcomes, whereas the other important predictors of outcome varied by rescue type (interventional or noninterventional). In a propensity score-matched analysis guided by SHAP-based variable selection, rescue therapy was associated with higher odds of 3-month GOS scores of 4-5 (OR 1.63, 95% CI 1.22-2.17). CONCLUSIONS Rescue therapy may increase the odds of good outcome in patients with aVSP or DCI after SAH. Given the strong association between cerebral ischemia/infarction and poor outcome, trials focusing on preventative or therapeutic interventions in these patients may be most able to demonstrate improvements in clinical outcomes. Insights developed from these models may be helpful for improving patient selection and trial design.
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Affiliation(s)
- Michael L Martini
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Sean N Neifert
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - William H Shuman
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Emily K Chapman
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | | | - Eric K Oermann
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - J Mocco
- 1Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Michael Todd
- 2Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota
| | - James C Torner
- 3Departments of Epidemiology, Surgery, and Neurosurgery, College of Public Health and Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Andrew Molyneux
- 4Nuffield Department of Surgical Sciences, University of Oxford, United Kingdom
| | - Stephan Mayer
- 5Wayne State University School of Medicine, Detroit, Michigan
| | | | - Mervyn D I Vergouwen
- 7Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- 7Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - George K C Wong
- 8Division of Neurosurgery, Prince of Wales Hospital and the Chinese University of Hong Kong, China
| | - Peter Kirkpatrick
- 9University of Cambridge, Nuffield Health Cambridge Hospital, Cambridge, United Kingdom
| | - Audrey Quinn
- 10Department of Anaesthesia, Cheriton House, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Daniel Hänggi
- 11Department of Neurosurgery, Düsseldorf University Hospital, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Nima Etminan
- 12Department of Neurosurgery, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Walter M van den Bergh
- 13Department of Critical Care, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Blessing N R Jaja
- Divisions of14Neurosurgery and.,15Neurology, St. Michael's Hospital, Toronto, Ontario.,16Neuroscience Research Program, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Surgery, University of Toronto, Ontario
| | - Michael Cusimano
- 17Education and Public Health, St. Michael's Hospital, University of Toronto, Keenan Research Centre and Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Tom A Schweizer
- 16Neuroscience Research Program, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Surgery, University of Toronto, Ontario
| | - Jose I Suarez
- 18Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hitoshi Fukuda
- 19Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki-city, Okayama, Japan
| | - Sen Yamagata
- 19Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki-city, Okayama, Japan
| | - Benjamin Lo
- 20Department of Neurosurgery, Lenox Hill Hospital, New York, New York
| | | | - Hieronymus D Boogaarts
- 22Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands; and
| | - R Loch Macdonald
- 23University of California San Francisco, Fresno Campus, University Neurosciences Institutes, Fresno, California
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Susa S, Rahmani R, Conover D, Carr S, Ellens N, Proper D, Le Roux P, Catapano J, Srinivasan V, Bhalla T. Safety of the Mobile Stroke Unit: A Descriptive Review and Results of Radiation Monitoring. Stroke 2021; 52:e497-e498. [PMID: 34082572 DOI: 10.1161/strokeaha.120.033545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen Susa
- Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.)
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.)
| | - David Conover
- Radiation Safety Unit, University of Rochester, NY (D.C., S.C.)
| | - Samuel Carr
- Radiation Safety Unit, University of Rochester, NY (D.C., S.C.)
| | - Nathaniel Ellens
- Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.)
| | - Diana Proper
- Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.)
| | - Peter Le Roux
- Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.).,Division of Neurosurgery, Bassett HealthCare, Cooperstown, NY (P.L.R.)
| | - Joshua Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (J.C., V.S.)
| | - Visish Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (J.C., V.S.)
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, NY (S.S., R.R., N.E., D.P., P.L.R., T.B.)
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Jaja BNR, Schweizer TA, Claassen J, Le Roux P, Mayer SA, Macdonald RL. The SAFARI Score to Assess the Risk of Convulsive Seizure During Admission for Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2019; 82:887-893. [PMID: 28973169 DOI: 10.1093/neuros/nyx334] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 05/17/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Seizure is a significant complication in patients under acute admission for aneurysmal SAH and could result in poor outcomes. Treatment strategies to optimize management will benefit from methods to better identify at-risk patients. OBJECTIVE To develop and validate a risk score for convulsive seizure during acute admission for SAH. METHODS A risk score was developed in 1500 patients from a single tertiary hospital and externally validated in 852 patients. Candidate predictors were identified by systematic review of the literature and were included in a backward stepwise logistic regression model with in-hospital seizure as a dependent variable. The risk score was assessed for discrimination using the area under the receiver operator characteristics curve (AUC) and for calibration using a goodness-of-fit test. RESULTS The SAFARI score, based on 4 items (age ≥ 60 yr, seizure occurrence before hospitalization, ruptured aneurysm in the anterior circulation, and hydrocephalus requiring cerebrospinal fluid diversion), had AUC = 0.77, 95% confidence interval (CI): 0.73-0.82 in the development cohort. The validation cohort had AUC = 0.65, 95% CI 0.56-0.73. A calibrated increase in the risk of seizure was noted with increasing SAFARI score points. CONCLUSION The SAFARI score is a simple tool that adequately stratified SAH patients according to their risk for seizure using a few readily derived predictor items. It may contribute to a more individualized management of seizure following SAH.
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Affiliation(s)
- Blessing N R Jaja
- Neuroscience Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Tom A Schweizer
- Department of Surgery, Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Jan Claassen
- Division of Critical Care Neurology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Peter Le Roux
- Thomas Jefferson University, Philadelphia, Pennsylvania.,Brain and Spine Center, Lankenau Medical Center, Wynnewood, Pennsylvania
| | | | - R Loch Macdonald
- Department of Surgery, Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada
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Jaja BNR, Saposnik G, Lingsma HF, Macdonald E, Thorpe KE, Mamdani M, Steyerberg EW, Molyneux A, Manoel ALDO, Schatlo B, Hanggi D, Hasan D, Wong GKC, Etminan N, Fukuda H, Torner J, Schaller KL, Suarez JI, Stienen MN, Vergouwen MDI, Rinkel GJE, Spears J, Cusimano MD, Todd M, Le Roux P, Kirkpatrick P, Pickard J, van den Bergh WM, Murray G, Johnston SC, Yamagata S, Mayer S, Schweizer TA, Macdonald RL. Development and validation of outcome prediction models for aneurysmal subarachnoid haemorrhage: the SAHIT multinational cohort study. BMJ 2018; 360:j5745. [PMID: 29348138 DOI: 10.1136/bmj.j5745] [Citation(s) in RCA: 150] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop and validate a set of practical prediction tools that reliably estimate the outcome of subarachnoid haemorrhage from ruptured intracranial aneurysms (SAH). DESIGN Cohort study with logistic regression analysis to combine predictors and treatment modality. SETTING Subarachnoid Haemorrhage International Trialists' (SAHIT) data repository, including randomised clinical trials, prospective observational studies, and hospital registries. PARTICIPANTS Researchers collaborated to pool datasets of prospective observational studies, hospital registries, and randomised clinical trials of SAH from multiple geographical regions to develop and validate clinical prediction models. MAIN OUTCOME MEASURE Predicted risk of mortality or functional outcome at three months according to score on the Glasgow outcome scale. RESULTS Clinical prediction models were developed with individual patient data from 10 936 patients and validated with data from 3355 patients after development of the model. In the validation cohort, a core model including patient age, premorbid hypertension, and neurological grade on admission to predict risk of functional outcome had good discrimination, with an area under the receiver operator characteristics curve (AUC) of 0.80 (95% confidence interval 0.78 to 0.82). When the core model was extended to a "neuroimaging model," with inclusion of clot volume, aneurysm size, and location, the AUC improved to 0.81 (0.79 to 0.84). A full model that extended the neuroimaging model by including treatment modality had AUC of 0.81 (0.79 to 0.83). Discrimination was lower for a similar set of models to predict risk of mortality (AUC for full model 0.76, 0.69 to 0.82). All models showed satisfactory calibration in the validation cohort. CONCLUSION The prediction models reliably estimate the outcome of patients who were managed in various settings for ruptured intracranial aneurysms that caused subarachnoid haemorrhage. The predictor items are readily derived at hospital admission. The web based SAHIT prognostic calculator (http://sahitscore.com) and the related app could be adjunctive tools to support management of patients.
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Affiliation(s)
- Blessing N R Jaja
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada
- Neuroscience Research Program of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, ON, Canada
| | - Gustavo Saposnik
- Division of Neurology, St Michael's Hospital, Toronto, ON, Canada
- Neuroscience Research Program of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, ON, Canada
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Erin Macdonald
- Neuroscience Research Program of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Kevin E Thorpe
- Department of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Muhammed Mamdani
- Institute of Medical Science, University of Toronto, ON, Canada
- Department of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, Netherlands
| | - Andrew Molyneux
- Division of Endovascular Neurosurgery, Department of Neurosurgery, University of Oxford, Oxford, UK
| | - Airton Leonardo de Oliveira Manoel
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada
- Neuroscience Research Program of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Bawarjan Schatlo
- Department of Neurosurgery, University Hospital Göttingen, Germany
| | - Daniel Hanggi
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg Theodor-Kutzer-Ufer 1-3, Germany
| | - David Hasan
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - George K C Wong
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg Theodor-Kutzer-Ufer 1-3, Germany
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki-city, Okayama, Japan
| | - James Torner
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Karl L Schaller
- Department of Clinical Neurosciences, Hôpitaux, Universitaire de Genève, Geneva, Switzerland
| | - Jose I Suarez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Mervyn D I Vergouwen
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, room G03-228, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Gabriel J E Rinkel
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, room G03-228, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Julian Spears
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada
- Department of Surgery, University of Toronto, ON, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, ON, Canada
- Department of Surgery, University of Toronto, ON, Canada
| | - Michael Todd
- Department of Anesthesia, University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Peter Le Roux
- The Brain and Spine Center, Lankenau Medical Center, Wynnewood, PA, USA
| | - Peter Kirkpatrick
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge CB2 0QQ, UK
| | - John Pickard
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Gordon Murray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | - Sen Yamagata
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki-city, Okayama, Japan
| | - Stephan Mayer
- Division of Critical Care Neurology, Columbia University College of Physicians and Surgeons, New York, USA
| | - Tom A Schweizer
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada
- Neuroscience Research Program of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, ON, Canada
- Department of Surgery, University of Toronto, ON, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada
- Neuroscience Research Program of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, ON, Canada
- Department of Surgery, University of Toronto, ON, Canada
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Kumar MA, Levine J, Faerber J, Elliott JP, Winn HR, Doerfler S, Le Roux P. The Effects of Red Blood Cell Transfusion on Functional Outcome after Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 108:807-816. [PMID: 29038077 DOI: 10.1016/j.wneu.2017.09.038] [Citation(s) in RCA: 14] [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: 09/22/2016] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal red blood cell transfusion (RBCT) trigger for patients with aneurysmal subarachnoid hemorrhage (SAH) is unknown. In patients with cerebral vasospasm, anemia may increase susceptibility to ischemic injury; conversely, RBCT may worsen outcome given known deleterious effects. OBJECTIVE To examine the association between RBCT, delayed cerebral ischemia (DCI), vasospasm, and outcome after SAH. METHODS A total of 421 consecutive patients with SAH, admitted to a neurocritical care unit at a university-affiliated hospital and who underwent surgical occlusion of their ruptured aneurysm were retrospectively identified from a prospective observational database. Propensity score methods were used to reduce the bias associated with treatment selection. RESULTS Two hundred and sixty-one patients (62.0%) received an RBCT. Angiographic vasospasm (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1-2.3; P = 0.025) but not severe angiographic spasm, DCI, or delayed infarction was associated with RBCT. A total of 283 patients (67.2%) experienced a favorable outcome, defined as good or moderately disabled on the Glasgow Outcome Scale; 47 (11.2%) were severely disabled or vegetative and 91 patients (21.6%) were dead at 6-month follow-up. Among patients who survived ≥2 days, RBCT was associated with unfavorable outcome (OR, 2.6; 95% CI, 1.6-4.1). Transfusion of ≥3 units of blood was associated with an increased incidence of unfavorable outcome. Propensity analysis to control for the probability of exposure to RBCT conditional on observed covariates measured before RBCT indicates that RBCT is associated with unfavorable outcome in the absence of DCI (OR, 2.17; 95% CI, 1.56-3.01; P < 0.0001) but not when DCI is present (OR, 0.82; 95% CI, 0.35-1.92; P = 0.65). CONCLUSIONS Blood transfusions are associated with unfavorable outcome after SAH particularly when DCI is absent. Propensity analysis suggests that RBCT may be associated with poor outcome rather than being a marker of disease severity. However, when DCI is present, RBCT may help improve outcome.
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Affiliation(s)
- Monisha A Kumar
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua Levine
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Faerber
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Paul Elliott
- Colorado Neurological Institute, Englewood, Colorado, USA
| | - H Richard Winn
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Sean Doerfler
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Le Roux
- Brain and Spine Center and Lankenau Institute of Medical Research Lankenau Medical Center, Wynnewood, Pennsylvania, USA.
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Chesnut RM, Bleck TP, Citerio G, Classen J, Cooper DJ, Coplin WM, Diringer MN, Grände PO, Hemphill JC, Hutchinson PJ, Le Roux P, Mayer SA, Menon DK, Myburgh JA, Okonkwo DO, Robertson CS, Sahuquillo J, Stocchetti N, Sung G, Temkin N, Vespa PM, Videtta W, Yonas H. A Consensus-Based Interpretation of the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure Trial. J Neurotrauma 2015; 32:1722-4. [DOI: 10.1089/neu.2015.3976] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Randall M. Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Thomas P. Bleck
- Department of Neurology, Rush University Medical Center, Chicago Illinois
| | - Giuseppe Citerio
- Department of Health Sciences, University of Milano-Bicocca, Milano, Italy
| | - Jan Classen
- Division of Critical Care Neurology and Comprehensive Epilepsy Center, Columbia University, New York, New York
| | - D. James Cooper
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
| | - William M. Coplin
- Neurosurgery Intensive Care, St. Anthony Hospital, Lakewood, Colorado
| | - Michael N. Diringer
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Per-Olof Grände
- Anesthesiology and Intensive Care, University Hospital of Lund, Lund, Sweden
| | - J. Claude Hemphill
- Departments of Neurology and Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Peter J. Hutchinson
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Peter Le Roux
- Neurosurgery, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Stephan A. Mayer
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David K. Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - John A. Myburgh
- Department of Intensive Care Medicine, University of New South Wales and the George Institute for Global Health, Sydney, Australia
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Juan Sahuquillo
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Nino Stocchetti
- Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gene Sung
- Department of Neurology, University of Southern California, Los Angeles, California
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Paul M. Vespa
- Department of Neurology, University of California Los Angeles, Los Angeles, California
| | - Walter Videtta
- Intensive Care Medicine, Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina
| | - Howard Yonas
- Department of Neurological Surgery, University of New Mexico, Albuquerque, New Mexico
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Vespa P, Menon D, Le Roux P. The International Multi-disciplinary Consensus Conference on Multimodality Monitoring: future directions and emerging technologies. Neurocrit Care 2015; 21 Suppl 2:S270-81. [PMID: 25208681 DOI: 10.1007/s12028-014-0049-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Neuromonitoring has evolved rapidly in recent years and there now are many new monitors that have revealed a great deal about the ongoing pathophysiology of brain injury and coma. Further evolution will include the consolidation of multi-modality monitoring (MMM), the development of next-generation informatics tools to identify complex physiologic events and decision support tools to permit targeted individualized care. In this review, we examine future directions and emerging technologies in neuromonitoring including: (1) device development, (2) what is the current limitation(s) of MMM in its present format(s), (3) what would improve the ability of MMM to enhance neurocritical care, and (4) how do we develop evidence for use of MMM?
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Affiliation(s)
- Paul Vespa
- Neurocritical Care, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Le Roux P, Menon DK, Citerio G, Vespa P, Bader MK, Brophy G, Diringer MN, Stocchetti N, Videtta W, Armonda R, Badjatia N, Bösel J, Chesnut R, Chou S, Claassen J, Czosnyka M, De Georgia M, Figaji A, Fugate J, Helbok R, Horowitz D, Hutchinson P, Kumar M, McNett M, Miller C, Naidech A, Oddo M, Olson D, O'Phelan K, Provencio JJ, Puppo C, Riker R, Roberson C, Schmidt M, Taccone F. The International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: a list of recommendations and additional conclusions: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Neurocrit Care 2015; 21 Suppl 2:S282-96. [PMID: 25501689 DOI: 10.1007/s12028-014-0077-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Careful patient monitoring using a variety of techniques including clinical and laboratory evaluation, bedside physiological monitoring with continuous or non-continuous techniques and imaging is fundamental to the care of patients who require neurocritical care. How best to perform and use bedside monitoring is still being elucidated. To create a basic platform for care and a foundation for further research the Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to develop recommendations about physiologic bedside monitoring. This supplement contains a Consensus Summary Statement with recommendations and individual topic reviews as a background to the recommendations. In this article, we highlight the recommendations and provide additional conclusions as an aid to the reader and to facilitate bedside care.
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Affiliation(s)
- Peter Le Roux
- Brain and Spine Center, Lankenau Medical Center, Suite 370, Medical Science Building, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA,
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9
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Chesnut R, Videtta W, Vespa P, Le Roux P. Intracranial pressure monitoring: fundamental considerations and rationale for monitoring. Neurocrit Care 2015; 21 Suppl 2:S64-84. [PMID: 25208680 DOI: 10.1007/s12028-014-0048-y] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability worldwide. In large part critical care for TBI is focused on the identification and management of secondary brain injury. This requires effective neuromonitoring that traditionally has centered on intracranial pressure (ICP). The purpose of this paper is to review the fundamental literature relative to the clinical application of ICP monitoring in TBI critical care and to provide recommendations on how the technique maybe applied to help patient management and enhance outcome. A PubMed search between 1980 and September 2013 identified 2,253 articles; 244 of which were reviewed in detail to prepare this report and the evidentiary tables. Several important concepts emerge from this review. ICP monitoring is safe and is best performed using a parenchymal monitor or ventricular catheter. While the indications for ICP monitoring are well established, there remains great variability in its use. Increased ICP, particularly the pattern of the increase and ICP refractory to treatment is associated with increased mortality. Class I evidence is lacking on how monitoring and management of ICP influences outcome. However, a large body of observational data suggests that ICP management has the potential to influence outcome, particularly when care is targeted and individualized and supplemented with data from other monitors including the clinical examination and imaging.
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Affiliation(s)
- Randall Chesnut
- Brain and Spine Center, Suite 370, Medical Science Building, Lankenau Medical Center, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA
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10
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Le Roux P, Menon DK, Citerio G, Vespa P, Bader MK, Brophy G, Diringer MN, Stocchetti N, Videtta W, Armonda R, Badjatia N, Bösel J, Chesnut R, Chou S, Claassen J, Czosnyka M, De Georgia M, Figaji A, Fugate J, Helbok R, Horowitz D, Hutchinson P, Kumar M, McNett M, Miller C, Naidech A, Oddo M, Olson D, O'Phelan K, Provencio JJ, Puppo C, Riker R, Roberson C, Schmidt M, Taccone F. The International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: evidentiary tables: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Neurocrit Care 2014; 21 Suppl 2:S297-361. [PMID: 25608916 PMCID: PMC10596300 DOI: 10.1007/s12028-014-0081-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [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] [Indexed: 11/25/2022]
Abstract
A variety of technologies have been developed to assist decision-making during the management of patients with acute brain injury who require intensive care. A large body of research has been generated describing these various technologies. The Neurocritical Care Society (NCS) in collaboration with the European Society of Intensive Care Medicine (ESICM), the Society for Critical Care Medicine (SCCM), and the Latin America Brain Injury Consortium (LABIC) organized an international, multidisciplinary consensus conference to perform a systematic review of the published literature to help develop evidence-based practice recommendations on bedside physiologic monitoring. This supplement contains a Consensus Summary Statement with recommendations and individual topic reviews on physiologic processes important in the care of acute brain injury. In this article we provide the evidentiary tables for select topics including systemic hemodynamics, intracranial pressure, brain and systemic oxygenation, EEG, brain metabolism, biomarkers, processes of care and monitoring in emerging economies to provide the clinician ready access to evidence that supports recommendations about neuromonitoring.
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Affiliation(s)
- Peter Le Roux
- Brain and Spine Center, Suite 370, Medical Science Building, Lankenau Medical Center, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA,
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11
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Le Roux P, Menon DK, Citerio G, Vespa P, Bader MK, Brophy GM, Diringer MN, Stocchetti N, Videtta W, Armonda R, Badjatia N, Böesel J, Chesnut R, Chou S, Claassen J, Czosnyka M, De Georgia M, Figaji A, Fugate J, Helbok R, Horowitz D, Hutchinson P, Kumar M, McNett M, Miller C, Naidech A, Oddo M, Olson D, O'Phelan K, Provencio JJ, Puppo C, Riker R, Robertson C, Schmidt M, Taccone F. Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Neurocrit Care 2014; 21 Suppl 2:S1-26. [PMID: 25208678 PMCID: PMC10596301 DOI: 10.1007/s12028-014-0041-5] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [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: 12/19/2022]
Abstract
Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants' collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.
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Affiliation(s)
- Peter Le Roux
- Brain and Spine Center, Suite 370, Medical Science Building, Lankenau Medical Center, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA,
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12
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Le Roux P, Pollack CV, Milan M, Schaefer A. Race against the clock: overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage. J Neurosurg 2014; 121 Suppl:1-20. [PMID: 25081496 DOI: 10.3171/2014.8.paradigm] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [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: 11/06/2022]
Abstract
Patients receiving anticoagulation therapy who present with any type of intracranial hemorrhage--including subdural hematoma, epidural hematoma, subarachnoid hemorrhage, and intracerebral hemorrhage (ICH)--require urgent correction of their coagulopathy to prevent hemorrhage expansion, limit tissue damage, and facilitate surgical intervention as necessary. The focus of this review is acute ICH, but the principles of management for anticoagulation-associated ICH (AAICH) apply to patients with all types of intracranial hemorrhage, whether acute or chronic. A number of therapies--including fresh frozen plasma (FFP), intravenous vitamin K, activated and inactivated prothrombin complex concentrates (PCCs), and recombinant activated factor VII (rFVIIa)--have been used alone or in combination to treat AAICH to reverse anticoagulation, help achieve hemodynamic stability, limit hematoma expansion, and prepare the patient for possible surgical intervention. However, there is a paucity of high-quality data to direct such therapy. The use of 3-factor PCC (activated and inactivated) and rFVIIa to treat AAICH constitutes off-label use of these therapies in the United States. However, in April 2013, the US Food and Drug Administration (FDA) approved Kcentra (a 4-factor PCC) for the urgent reversal of vitamin K antagonist (VKA) anticoagulation in adults with acute major bleeding. Plasma is the only other product approved for this use in the United States. (1) Inconsistent recommendations, significant barriers (e.g., clinician-, therapy-, or logistics-based barriers), and a lack of approved treatment pathways in some institutions can be potential impediments to timely and evidence-based management of AAICH with available therapies. Patient assessment, therapy selection, whether to use a reversal or factor repletion agent alone or in combination with other agents, determination of site-of-care management, eligibility for neurosurgery, and potential hematoma evacuation are the responsibilities of the neurosurgeon, but ultimate success requires a multidisciplinary approach with consultation from the emergency department (ED) physician, pharmacist, hematologist, intensivist, neurologist, and, in some cases, the trauma surgeon.
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Affiliation(s)
- Peter Le Roux
- Thomas Jefferson University, Philadelphia, Pennsylvania and Brain and Spine Center, Lankenau Medical Center, Wynnewood, Pennsylvania
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13
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Le Roux P, Menon DK, Citerio G, Vespa P, Bader MK, Brophy GM, Diringer MN, Stocchetti N, Videtta W, Armonda R, Badjatia N, Böesel J, Chesnut R, Chou S, Claassen J, Czosnyka M, De Georgia M, Figaji A, Fugate J, Helbok R, Horowitz D, Hutchinson P, Kumar M, McNett M, Miller C, Naidech A, Oddo M, Olson D, O'Phelan K, Provencio JJ, Puppo C, Riker R, Robertson C, Schmidt M, Taccone F. Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care : a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40:1189-209. [PMID: 25138226 DOI: 10.1007/s00134-014-3369-6] [Citation(s) in RCA: 197] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 06/07/2014] [Indexed: 12/18/2022]
Abstract
Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants' collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.
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Affiliation(s)
- Peter Le Roux
- Brain and Spine Center, Suite 370, Medical Science Building, Lankenau Medical Center, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA,
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14
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Jaja BNR, Attalla D, Macdonald RL, Schweizer TA, Cusimano MD, Etminan N, Hanggi D, Hasan D, Johnston SC, Le Roux P, Lo B, Louffat-Olivares A, Mayer S, Molyneux A, Noble A, Quinn A, Schenk T, Spears J, Singh J, Todd M, Torner J, Tseng M, van den Bergh W, Vergouwen MDI, Wong GKC. The Subarachnoid Hemorrhage International Trialists (SAHIT) Repository: Advancing Clinical Research in Subarachnoid Hemorrhage. Neurocrit Care 2014; 21:551-9. [DOI: 10.1007/s12028-014-9990-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Abstract
Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Despite encouraging animal research, pharmacological agents and neuroprotectants have disappointed in the clinical environment. Current TBI management therefore is directed towards identification, prevention, and treatment of secondary cerebral insults that are known to exacerbate outcome after injury. This strategy is based on a variety of monitoring techniques that include the neurological examination, imaging, laboratory analysis, and physiological monitoring of the brain and other organ systems used to guide therapeutic interventions. Recent clinical series suggest that TBI management informed by multimodality monitoring is associated with improved patient outcome, in part because care is provided in a patient-specific manner. In this review we discuss physiological monitoring of the brain after TBI and the emerging field of neurocritical care bioinformatics.
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Affiliation(s)
- Peter Le Roux
- Department of Neurosurgery, University of Pennsylvania, 235 South 8th Street, Philadelphia, PA 19106, USA.
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16
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Stocchetti N, Le Roux P, Vespa P, Oddo M, Citerio G, Andrews PJ, Stevens RD, Sharshar T, Taccone FS, Vincent JL. Clinical review: neuromonitoring - an update. Crit Care 2013; 17:201. [PMID: 23320763 PMCID: PMC4057243 DOI: 10.1186/cc11513] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Critically ill patients are frequently at risk of neurological dysfunction as a result of primary neurological conditions or secondary insults. Determining which aspects of brain function are affected and how best to manage the neurological dysfunction can often be difficult and is complicated by the limited information that can be gained from clinical examination in such patients and the effects of therapies, notably sedation, on neurological function. Methods to measure and monitor brain function have evolved considerably in recent years and now play an important role in the evaluation and management of patients with brain injury. Importantly, no single technique is ideal for all patients and different variables will need to be monitored in different patients; in many patients, a combination of monitoring techniques will be needed. Although clinical studies support the physiologic feasibility and biologic plausibility of management based on information from various monitors, data supporting this concept from randomized trials are still required.
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17
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Macdonald RL, Cusimano MD, Etminan N, Hanggi D, Hasan D, Ilodigwe D, Jaja B, Lantigua H, Le Roux P, Lo B, Louffat-Olivares A, Mayer S, Molyneux A, Quinn A, Schweizer TA, Schenk T, Spears J, Todd M, Torner J, Vergouwen MDI, Wong GKC. Subarachnoid Hemorrhage International Trialists data repository (SAHIT). World Neurosurg 2013; 79:418-22. [PMID: 23295631 DOI: 10.1016/j.wneu.2013.01.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Accepted: 01/03/2013] [Indexed: 11/17/2022]
Abstract
The outcome of patients with aneurysmal subarachnoid hemorrhage (SAH) has improved slowly over the past 25 years. This improvement may be due to early aneurysm repair by endovascular or open means, use of nimodipine, and better critical care management. Despite this improvement, mortality remains at about 40%, and many survivors have permanent neurologic, cognitive, and neuropsychologic deficits. Randomized clinical trials have tested pharmacologic therapies, but few have been successful. There are numerous explanations for the failure of these trials, including ineffective interventions, inadequate sample size, treatment side effects, and insensitive or inappropriate outcome measures. Outcome often is evaluated on a good-bad dichotomous scale that was developed for traumatic brain injury 40 years ago. To address these issues, we established the Subarachnoid Hemorrhage International Trialists (SAHIT) data repository. The primary aim of the SAHIT data repository is to provide a unique resource for prognostic analysis and for studies aimed at optimizing the design and analysis of phase III trials in aneurysmal SAH. With this aim in mind, we convened a multinational investigator meeting to explore merging individual patient data from multiple clinical trials and observational databases of patients with SAH and to create an agreement under which such a group of investigators could submit data and collaborate. We welcome collaboration with other investigators.
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Affiliation(s)
- R Loch Macdonald
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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18
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Larach DB, Kofke WA, Le Roux P. Potential non-hypoxic/ischemic causes of increased cerebral interstitial fluid lactate/pyruvate ratio: a review of available literature. Neurocrit Care 2012; 15:609-22. [PMID: 21336786 DOI: 10.1007/s12028-011-9517-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Microdialysis, an in vivo technique that permits collection and analysis of small molecular weight substances from the interstitial space, was developed more than 30 years ago and introduced into the clinical neurosciences in the 1990s. Today cerebral microdialysis is an established, commercially available clinical tool that is focused primarily on markers of cerebral energy metabolism (glucose, lactate, and pyruvate) and cell damage (glycerol), and neurotransmitters (glutamate). Although the brain comprises only 2% of body weight, it consumes 20% of total body energy. Consequently, the ability to monitor cerebral metabolism can provide significant insights during clinical care. Measurements of lactate, pyruvate, and glucose give information about the comparative contributions of aerobic and anaerobic metabolisms to brain energy. The lactate/pyruvate ratio reflects cytoplasmic redox state and thus provides information about tissue oxygenation. An elevated lactate pyruvate ratio (>40) frequently is interpreted as a sign of cerebral hypoxia or ischemia. However, several other factors may contribute to an elevated LPR. This article reviews potential non-hypoxic/ischemic causes of an increased LPR.
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Affiliation(s)
- Daniel B Larach
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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19
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Le Roux P, Diringer M. The Risks of Blood Transfusion in Patients with Subarachnoid Hemorrhage: Response to Dr. Paul E. Marik. Neurocrit Care 2012. [DOI: 10.1007/s12028-012-9674-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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20
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Abstract
OPINION STATEMENT: Anemia develops in about 50% of patients hospitalized with traumatic brain injury (TBI) and is recognized as a cause of secondary brain injury. This review examines the effects of anemia and transfusion on TBI patients through a literature search to identify original research on anemia and transfusion in TBI, the effects of transfusion on brain physiology, and the role of erythropoietin or hemoglobin-based blood substitutes (HBBSs). However, the amount of high-quality, prospective data available to help make decisions about when TBI patients should be transfused is very small. Randomized transfusion trials have involved far too few TBI patients to reach definitive conclusions. Thus, it is hardly surprising that there is widespread practice variation. In our opinion, a hemoglobin transfusion threshold of 7 g/dL cannot yet be considered safe for TBI patients admitted to hospital, and in particular to the ICU, as it is for other critically ill patients. Red blood cell transfusions often have immediate, seemingly beneficial effects on cerebral physiology, but the magnitude of this effect may depend in part upon how long the cells have been stored before administration. In light of existing physiological data, we generally aim to keep hemoglobin concentrations greater than 9 g/dL during the first several days after TBI. In part, the decision is based on the patient's risk of or development of secondary ischemia or brain injury. An increasing number of centers use multimodal neurologic monitoring, which may help to individualize transfusion goals based on the degree of cerebral hypoxia or metabolic distress. When available, brain tissue oxygen tension values less than 15-20 mm Hg or a lactate:pyruvate ratio greater than 30-40 would influence us to use more aggressive hemoglobin correction (e.g., a transfusion threshold of 10 g/dL). Clinicians can attempt to reduce transfusion requirements by limiting phlebotomy, minimizing hemodilution, and providing appropriate prophylaxis against gastrointestinal hemorrhage. Administration of exogenous erythropoietin may have a small impact in further reducing the need for transfusion, but it also may increase complications, most notably deep venous thrombosis. Erythropoietin is currently of great interest as a potential neuroprotective agent, but until it is adequately evaluated in randomized controlled trials, it should not be used routinely for this purpose. HBBSs are also of interest, but existing preparations have not been shown to be beneficial-or even safe-in the context of TBI.
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Affiliation(s)
- Andreas H Kramer
- Department of Critical Care Medicine & Clinical Neurosciences, University of Calgary, Ground Floor, McCaig Tower, 3134 Hospital Dr NW, Calgary, AB, T2N 2T9, Canada
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Diringer MN, Bleck TP, Claude Hemphill J, Menon D, Shutter L, Vespa P, Bruder N, Connolly ES, Citerio G, Gress D, Hänggi D, Hoh BL, Lanzino G, Le Roux P, Rabinstein A, Schmutzhard E, Stocchetti N, Suarez JI, Treggiari M, Tseng MY, Vergouwen MDI, Wolf S, Zipfel G. Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care 2011; 15:211-40. [DOI: 10.1007/s12028-011-9605-9] [Citation(s) in RCA: 754] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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22
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Sangster P, Symes A, Walker R, Morley R, Thompson A, Dick J, Le Roux P, Sandhu S. 1356 A MULTI-INSTITUTIONAL ANALYSIS OF PATIENT OUTCOMES FOLLOWING INTRAVESICAL BACILLUS CALMETTE-GUERIN TREATMENT FOR NON-MUSCLE INVASIVE BLADDER CANCER. J Urol 2010. [DOI: 10.1016/j.juro.2010.02.983] [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: 10/19/2022]
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23
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Levine J, Kofke A, Cen L, Chen Z, Faerber J, Elliott JP, Winn HR, Le Roux P. Red Blood Cell Transfusion Is Associated With Infection and Extracerebral Complications After Subarachnoid Hemorrhage. Neurosurgery 2010; 66:312-8; discussion 318. [DOI: 10.1227/01.neu.0000363747.47587.6c] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Red blood cell transfusion (RBCT) is associated with medical complications in general medical and surgical patients. We examined the hypothesis that RBCT during intensive care unit (ICU) care is associated with medical complications after subarachnoid hemorrhage (SAH).
METHODS
We retrospectively analyzed a prospective observational database containing 421 patients with SAH (mean age, 51.5 years; standard deviation, 14.6 years). Logistic regression models were used to adjust for age, admission hemoglobin (Hgb), clinical grade, average ICU Hgb, and symptomatic vasospasm.
RESULTS
Two hundred fourteen patients received an RBCT during their ICU stay. Medical complications were identified in 156 patients and were more common in those who received blood (46%) than in those who did not (29.8%) (P < .001). Major medical complications (cardiac, pulmonary, renal, or hepatic) occurred in 111 patients, and minor complications (eg, skin rash, deep vein thrombosis) occurred in 45 patients. Any non–central nervous system infection (n = 183; P < .001), including pneumonia (n = 103; P < .001) or septicemia (n = 36; P = .02), was more common with RBCT. Central nervous system infections (meningitis, cranial wound, n = 15) also were associated with RBCT (P = .03). Mechanically ventilated patients (n = 259) were more likely to have received an RBCT than those who did not (P < .001). When logistic regression was used to control for age, admission clinical grade and Hgb, average ICU Hgb, symptomatic vasospasm, and other admission variables associated with outcome, the following factors (odds ratio; 95% confidence interval) were associated with RBCT: any medical complication (1.8; 1.1–3.0), major medical complications (2.1; 1.2–3.7), any infection (2.8; 1.7–4.5), pneumonia (2.6; 1.5–4.7), septicemia (2.9; 1.2–6.8), and need for mechanical ventilation (2.8; 1.5–5.1).
CONCLUSION
These data suggest that RBCTs are associated with medical complications after SAH. However, the data do not infer causation, and further study is necessary to better define the indications for transfusion after SAH.
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Affiliation(s)
- Joshua Levine
- Departments of Neurosurgery, Neurology, and Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania (Levine) (Kofke)
| | - Andrew Kofke
- Departments of Neurosurgery, Neurology, and Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania (Levine) (Kofke)
| | - Liyi Cen
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania (Cen) (Chen) (Faerber)
| | - Zhen Chen
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania (Cen) (Chen) (Faerber)
| | - Jennifer Faerber
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania (Cen) (Chen) (Faerber)
| | - J. Paul Elliott
- Colorado Neurological Institute, Englewood, Colorado (Elliott)
| | - H. Richard Winn
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York (Winn)
| | - Peter Le Roux
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania (Roux)
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Ramakrishna R, Stiefel M, Udoetuk J, Spiotta A, Levine JM, Kofke WA, Zager E, Yang W, Le Roux P. Erratum. J Neurosurg 2009. [DOI: 10.3171/jns.2008.109.12.1075a] [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: 11/06/2022]
Affiliation(s)
| | | | | | | | | | | | - Eric Zager
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Le Roux
- University of Pennsylvania, Philadelphia, Pennsylvania
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Ramakrishna R, Stiefel M, Udoetuk J, Spiotta A, Levine JM, Kofke WA, Zager E, Yang W, Le Roux P. Erratum. J Neurosurg 2009; 110:613. [DOI: 10.3171/jns.2009.110.3.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Ramakrishna R, Stiefel M, Udoetuk J, Wilensky EM, Zager E, Roux PL. Age and Brain Oxygen in patients with Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2006. [DOI: 10.1227/01.neu.0000310219.56742.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
Glutamate is an important regulator of dendrite development. During cerebral ischemia, however, there is massive release of glutamate reaching millimolar concentrations in the extracellular space. An early consequence of this excess glutamate is reduced dendrite growth. Bone morphogenetic protein-7 (BMP-7) a member of the transforming growth factor-beta (TGF-beta) superfamily has been demonstrated to enhance dendrite output from cerebral cortical and hippocampal neurons in vitro. However, it is not known whether BMP-7can prevent the reduced dendrite growth associated with excess glutamate or enhance dendrite growth after glutamate exposure. Therefore we quantified axon and primary, secondary, and total dendrite growth from embryonic mouse cortical neurons (E18) grown at low density in vitro in a chemically defined medium and exposed to glutamate (1 or 2 mM) for 48 h. Morphology and double immunolabeling (MAP2, NF-H) were used to identify cortical dendrites and axons after 3 DIV. In these short-term cultures, glutamate did not influence neuron survival. The addition of glutamate to cortical neurons, however, significantly attenuated dendrite output. This effect was mimicked by the addition of NMDA but not AMPA agonists and inhibited by the specific NMDA receptor antagonist MK-801. The reduction in dendrite growth mediated by excess glutamate was ameliorated by the administration of 30 or 100 ng/ml of BMP-7. In addition, when administered in a delayed fashion between 1 and 24 h after the initial glutamate exposure, BMP-7 was able to enhance dendrite growth, including primary dendrite number, primary dendrite length, and secondary dendritic branching. These findings demonstrate that BMP-7 can ameliorate reduced dendrite growth from cerebral cortical neurons associated with excess glutamate in vitro and are important because they may help explain why BMP-7 administration is associated with enhanced functional recovery in models of cerebral ischemia.
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Affiliation(s)
- Susana Esquenazi
- Department of Neurosurgery, New York University, New York, New York, USA
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Roux PL. [Seminar in Clinical Virology: the respiratory viruses. Caen, France, 5-6 October 2000]. Ann Biol Clin (Paris) 2001; 59:210-3. [PMID: 11282526] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Affiliation(s)
- P L Roux
- Service de pédiatrie, Groupe hospitalier du Havre, BP 24, 76083 Le Havre cedex
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