Abstract
Brain hypoxia can occur after non-traumatic subarachnoid hemorrhage (SAH), even when levels of intracranial pressure (ICP) remain normal. Brain tissue oxygenation (PbtO
2
) can be measured ...as a part of a neurological multimodal neuromonitoring. Low PbtO
2
has been associated with poor neurologic recovery. There is scarce data on the impact of PbtO
2
guided-therapy on patients’ outcome. This single-center cohort study (June 2014–March 2020) included all patients admitted to the ICU after SAH who required multimodal monitoring. Patients with imminent brain death were excluded. Our primary goal was to assess the impact of PbtO
2
-guided therapy on neurological outcome. Secondary outcome included the association of brain hypoxia with outcome. Of the 163 patients that underwent ICP monitoring, 62 were monitored with PbtO
2
and 54 (87%) had at least one episode of brain hypoxia. In patients that required treatment based on neuromonitoring strategies, PbtO
2
-guided therapy (OR 0.33 CI 95% 0.12–0.89) compared to ICP-guided therapy had a protective effect on neurological outcome at 6 months. In this cohort of SAH patients, PbtO
2
-guided therapy might be associated with improved long-term neurological outcome, only when compared to ICP-guided therapy.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Due to heterogenous seizure semiology and poor contribution of scalp electroencephalography (EEG) signals, insular epilepsy requires use of the appropriate diagnostic tools for its diagnosis and ...characterization. The deep location of the insula also presents surgical challenges. The aim of this article is to review the current diagnostic and therapeutic tools and their contribution to the management of insular epilepsy. Magnetic resonance imaging (MRI), isotopic imaging, neurophysiological imaging, and genetic testing should be used and interpretated with caution. Isotopic imaging and scalp EEG have demonstrated a lower value in epilepsy from insular compared to temporal origin, which increases the interest of functional MRI and magnetoencephalography. Intracranial recording with stereo‐electroencephalography (SEEG) is often required. The insular cortex, being highly connected and deeply located under highly functional areas, is difficult to reach, and its ablative surgery raises functional issues. Tailored resection based on SEEG or alternative curative treatments, such as radiofrequency thermocoagulation, laser interstitial thermal therapy, or stereotactic radiosurgery, have produced encouraging results. The management of insular epilepsy has benefited from major advances in the last years. Perspectives for diagnostic and therapeutic procedures will contribute to better management of this complex form of epilepsy.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Abstract
Cerebral hypoxia is an important cause of secondary brain injury. Improving systemic oxygenation may increase brain tissue oxygenation (PbtO
2
). The effects of increased positive ...end-expiratory pressure (PEEP) on PbtO
2
and intracranial pressure (ICP) needs to be further elucidated. This is a single center retrospective cohort study (2016–2021) conducted in a 34-bed Department of Intensive Care unit. All patients with acute brain injury under mechanical ventilation who were monitored with intracranial pressure and brain tissue oxygenation (PbtO
2
) catheters and underwent at least one PEEP increment were included in the study. Primary outcome was the rate of PbtO
2
responders (increase in PbtO
2
> 20% of baseline) after PEEP increase. ΔPEEP was defined as the difference between PEEP at 1 h and PEEP at baseline; similarly ΔPbtO
2
was defined as the difference between PbtO
2
at 1 h after PEEP incrementation and PbtO
2
at baseline. We included 112 patients who underwent 295 episodes of PEEP increase. Overall, the median PEEP increased form 6 (IQR 5–8) to 10 (IQR 8–12) cmH
2
O (p = 0.001), the median PbtO
2
increased from 21 (IQR 16–29) mmHg to 23 (IQR 18–30) mmHg (p = 0.001), while ICP remained unchanged from 12 (7–18) mmHg to 12 (7–17) mmHg; p = 0.42. Of 163 episode of PEEP increments with concomitant PbtO
2
monitoring, 34 (21%) were PbtO
2
responders. A lower baseline PbtO
2
(OR 0.83 0.73–0.96)) was associated with the probability of being responder. ICP increased in 142/295 episodes of PEEP increments (58%); no baseline variable was able to identify this response. In PbtO
2
responders there was a moderate positive correlation between ΔPbtO
2
and ΔPEEP (r = 0.459 95% CI 0.133–0.696. The response in PbtO
2
and ICP to PEEP elevations in brain injury patients is highly variable. Lower PbtO
2
values at baseline could predict a significant increase in brain oxygenation after PEEP increase.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Background and purpose
Daily management of patients with foot drop due to peroneal nerve entrapment varies between a purely conservative treatment and early surgery, with no high‐quality evidence to ...guide current practice. Electrodiagnostic (EDX) prognostic features and the value of imaging in establishing and supplementing the diagnosis have not been clearly established.
Methods
We performed a literature search in the online databases MEDLINE, Embase, and the Cochrane Library. Of the 42 unique articles meeting the eligibility criteria, 10 discussed diagnostic performance of imaging, 11 reported EDX limits for abnormal values and/or the value of EDX in prognostication, and 26 focused on treatment outcome.
Results
Studies report high sensitivity and specificity of both ultrasound (varying respectively from 47.1% to 91% and from 53% to 100%) and magnetic resonance imaging (MRI; varying respectively from 31% to 100% and from 73% to 100%). One comparative trial favoured ultrasound over MRI. Variable criteria for a conduction block (>20%–≥50) were reported. A motor conduction block and any baseline compound motor action potential response were identified as predictors of good outcome. Based predominantly on case series, the percentage of patients with good outcome ranged 0%–100% after conservative treatment and 40%−100% after neurolysis. No study compared both treatments.
Conclusions
Ultrasound and MRI have good accuracy, and introducing imaging in the standard diagnostic workup should be considered. Further research should focus on the role of EDX in prognostication. No recommendation on the optimal treatment strategy of peroneal nerve entrapment can be made, warranting future randomized controlled trials.
This scoping review mainly maps all available evidence for the treatment of foot drop due to peroneal nerve entrapment and concludes that there is insufficient evidence to support either a conservative or a surgical treatment. Furthermore, diagnostic accuracy of ultrasound and magnetic resonance imaging is compared. We also summarize reported criteria for a conduction block as well as prognostic measures in electrodiagnostic studies and investigate the added value of electrodiagnostic studies in prognostication.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Intracranial multimodality monitoring (iMMM) is increasingly used in acute brain-injured patients; however, safety and reliability remain major concerns to its routine implementation.
...Methods
We performed a retrospective study including all patients undergoing iMMM at a single European center between July 2016 and January 2020. Brain tissue oxygenation probe (PbtO
2
), alone or in combination with a microdialysis catheter and/or an 8-contact depth EEG electrode, was inserted using a triple-lumen bolt system and targeting normal-appearing at-risk brain area on the injured side, whenever possible. Surgical complications, adverse events, and technical malfunctions, directly associated with iMMM, were collected. A blinded imaging review was performed by an independent radiologist.
Results
One hundred thirteen patients with 123 iMMM insertions were included for a median monitoring time of 9 3–14 days. Of those, 93 (76%) patients had only PbtO
2
probe insertion and 30 (24%) had also microdialysis and/or iEEG monitoring. SAH was the most frequent indication for iMMM (
n
= 60, 53%). At least one complication was observed in 67/123 (54%) iMMM placement, corresponding to 58/113 (51%) patients. Misplacement was observed in 16/123 (13%), resulting in a total of 6/16 (38%) malfunctioning PbtO
2
catheters. Intracranial hemorrhage was observed in 14 iMMM placements (11%), of which one required surgical drainage. Five placements were complicated by pneumocephalus and 4 with bone fragments; none of these requires additional surgery. No CNS infection related to iMMM was observed. Seven (6%) probes were accidentally dislodged and 2 probes (2%) were accidentally broken. Ten PbtO
2
probes (8%) presented a technical malfunction after a median of 9 ranges: 2–24 days after initiation of monitoring and 4 of them were replaced.
Conclusions
In this study, a high occurrence of complications related to iMMM was observed, although most of them did not require specific interventions and did not result in malfunctioning monitoring.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Introduction
Tissue hypoxia and insufficient energy delivery is one of the mechanisms behind the occurrence of several complications in acute brain injured patients. Several interventions can improve ...cerebral oxygenation; however, the effects of inotropic agents remain poorly characterized.
Methods
Retrospective analysis including patients suffering from acute brain injury and monitored with brain oxygen pressure (PbtO
2
) catheter, in whom inotropic agents were administered according to the decision of the treating physician's decision; PbtO
2
values were collected before, 1 and 2 h after the initiation of therapy from the patient data monitoring system. PbtO
2
“responders” were patients with a relative increase in PbtO
2
from baseline values of at least 20%.
Results
A total of 35 patients were included in this study. Most of them (31/35, 89%) suffered from non-traumatic subarachnoid hemorrhage (SAH). Compared with baseline values 20 (14–24) mmHg, PbtO
2
did not significantly increase over time 19 (15–25) mmHg at 1 h and 19 (17–25) mmHg at 2 h, respectively;
p
= 0.052. A total of 12/35 (34%) patients were PbtO
2
“responders,” in particular if low PbtO
2
was observed at baseline. A PbtO
2
of 17 mmHg at baseline had a sensibility of 84% and a specificity of 91% to predict a PbtO
2
responder. A significant direct correlation between changes in PbtO
2
and cardiac output r = 0.496 (95% CI 0.122 to 0.746),
p
= 0.01;
n
= 25 and a significant negative correlation between changes in PbtO
2
and cerebral perfusion pressure
r
= −0.389 (95% CI −0.681 to −0.010),
p
= 0.05 were observed.
Conclusions
In this study, inotropic administration significantly increased brain oxygenation in one third of brain injured patients, especially when tissue hypoxia was present at baseline. Future studies should highlight the role of inotropic agents in the management of tissue hypoxia in this setting.
Neurological outcome and mortality of patients suffering from poor grade subarachnoid hemorrhage (SAH) may have changed over time. Several factors, including patients' characteristics, the presence ...of hydrocephalus and intraparenchymal hematoma, might also contribute to this effect. The aim of this study was to assess the temporal changes in mortality and neurologic outcome in SAH patients and identify their predictors.
We performed a single center retrospective cohort study from 2004 to 2018. All non-traumatic SAH patients with poor grade on admission (WFNS score of 4 or 5) who remained at least 24 h in the hospital were included. Time course was analyzed into four groups according to the years of admission (2004-2007; 2008-2011; 2012-2015 and 2016-2018).
A total of 353 patients were included in this study: 202 patients died (57 %) and 260 (74 %) had unfavorable neurological outcome (UO) at 3 months. Mortality tended to decrease in in 2008-2011 and 2016-2018 periods (HR 0.55 0.34-0.89 and HR 0.33 0.20-0.53, respectively, when compared to 2004-2007). The proportion of patients with UO remained high and did not vary significantly over time. Patients with WFNS 5 had higher mortality (68 % vs. 34 %, p = 0.001) and more frequent UO (83 % vs. 54 %, p = 0.001) than those with WFNS 4. In the multivariable analysis, WFNS 5 was independently associated with mortality (HR 2.12 1.43-3.14) and UO (OR 3.23 1.67-6.25). The presence of hydrocephalus was associated with a lower risk of mortality (HR 0.60 0.43-0.84).
Both hospital mortality and UO remained high in poor grade SAH patients. Patients with WFNS 5 on admission had worse prognosis than others; this should be taken into consideration for future clinical studies.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Serum lactate dehydrogenase (LDH) levels are often elevated in cardiovascular diseases. Their prognostic role after subarachnoid hemorrhage (SAH) remains poorly evaluated.
This is a retrospective ...single-center study of patients with non-traumatic SAH admitted to the intensive care unit (ICU) of an University Hospital from 2007 to 2022. Exclusion criteria were pregnancy and incomplete medical records or follow-up data. Baseline information, clinical data, radiologic data, the occurrence of neurological complications as well as serum LDH levels during the first 14 days of ICU stay were collected. Unfavorable neurological outcome (UO) at 3 months was defined as a Glasgow Outcome Scale of 1-3.
Five hundred and forty-seven patients were included; median serum LDH values on admission and the highest LDH values during the ICU stay were 192 160-230 IU/L and 263 202-351 IU/L, respectively. The highest LDH value was recorded after a median of 4 2-10 days after ICU admission. LDH levels on admission were significantly higher in patients with UO. When compared with patients with favorable outcome (FO), patients with UO had higher serum LDH values over time. In the multivariate logistic regression model, the highest LDH value over the ICU stay (OR 1.004 95% CI 1.002 - 1.006) was independently associated with the occurrence of UO; the area under the receiving operator (AUROC) curve for the highest LDH value over the ICU stay showed a moderate accuracy to predict UO (AUC 0.76 95% CI 0.72-0.80; p < 0.001), with an optimal threshold of > 272 IU/L (69% sensitivity and 74% specificity).
The results in this study suggest that high serum LDH levels are associated with the occurrence of UO in SAH patients. As a readily and available biomarker, serum LDH levels should be evaluated to help with the prognostication of SAH patients.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background:
Although increasing cerebral perfusion pressure (CPP) is commonly accepted to improve brain tissue oxygen pressure (PbtO
2
), it remains unclear whether recommended CPP targets (i. e., ...>60 mmHg) would result in adequate brain oxygenation in brain injured patients. The aim of this study was to identify the target of CPP associated with normal brain oxygenation.
Methods:
Prospectively collected data including patients suffering from acute brain injury and monitored with PbtO
2
, in whom daily CPP challenge using vasopressors was performed. Initial CPP target was >60 mmHg; norepinephrine infusion was modified to have an increase in CPP of at least 10 mmHg at two different steps above the baseline values. Whenever possible, the same CPP challenge was performed for the following days, for a maximum of 5 days. CPP “responders” were patients with a relative increase in PbtO
2
from baseline values > 20%.
Results:
A total of 53 patients were included. On the first day of assessment, CPP was progressively increased from 73 (70–76) to 83 (80–86), and 92 (90–96) mmHg, which resulted into a significant PbtO
2
increase from 20 (17–23) mmHg to 22 (20–24) mmHg and 24 (22–26) mmHg, respectively;
p
< 0.001. Median CPP value corresponding to PbtO
2
values > 20 mmHg was 79 (74–87) mmHg, with 2 (4%) patients who never achieved such target. Similar results of CPP targets were observed the following days. A total of 25 (47%) were PbtO
2
responders during the CPP challenge on day 1, in particular if low PbtO
2
was observed at baseline.
Conclusions:
PbtO
2
monitoring can be an effective way to individualize CPP values to avoid tissue hypoxia. Low PbtO
2
values at baseline can identify the responders to the CPP challenge.
Acetazolamide is a non-competitive inhibitor of carbonic anhydrase, an enzyme expressed in different cells of the central nervous system (CNS) and involved in the regulation of cerebral blood flow ...(CBF). The aim of this review was to understand the effects of acetazolamide on CBF, intracranial pressure (ICP) and brain tissue oxygenation (PbtO
) after an acute brain injury (ABI).
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA), we performed a comprehensive, computer-based, literature research on the PubMed platform to identify studies that have reported the effects on CBF, ICP, or PbtO
of acetazolamide administered either for therapeutic or diagnostic purposes in patients with subarachnoid hemorrhage, intracerebral hemorrhage, traumatic brain injury, and hypoxic-ischemic encephalopathy.
From the initial search, 3430 records were identified and, through data selection, 11 of them were included for the qualitative analysis. No data on the effect of acetazolamide on ICP or PbtO
were found. Cerebral vasomotor reactivity (VMR-i.e., the changing in vascular tone due to a vasoactive substance) to acetazolamide tends to change during the evolution of ABI, with the nadir occurring during the subacute stage. Moreover, VMR reduction was correlated with clinical outcome.
This systematic review showed that the available studies on the effects of acetazolamide on brain hemodynamics in patients with ABI are scarce. Further research is required to better understand the potential role of this drug in ABI patients.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
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