Prevalence and Risk Factor Analysis of Post-Intensive Care Syndrome in Patients with COVID-19 Requiring Mechanical Ventilation: A Multicenter Prospective Observational Study.

INTRODUCTION: Post-intensive care syndrome (PICS) is an emerging problem in critically ill patients and the prevalence and risk factors are unclear in patients with severe coronavirus disease 2019 (COVID-19). This multicenter prospective observational study aimed to investigate the prevalence and risk factors of PICS in ventilated patients with COVID-19 after ICU discharge. METHODS: Questionnaires were administered twice in surviving patients with COVID-19 who had required mechanical ventilation, concerning Barthel Index, Short-Memory Questionnaire, and Hospital Anxiety and Depression Scale scores. The risk factors for PICS were examined using a multivariate logistic regression analysis. RESULTS: The first and second PICS surveys were obtained at 5.5 and 13.5 months (mean) after ICU discharge, with 251 and 209 patients completing the questionnaires and with a prevalence of PICS of 58.6% and 60.8%, respectively, along with the highest percentages of cognitive impairment. Delirium (with an odds ratio of (OR) 2.34, 95% CI 1.1-4.9, and p = 0.03) and the duration of mechanical ventilation (with an OR of 1.29, 95% CI 1.05-1.58, and p = 0.02) were independently identified as the risk factors for PICS in the first PICS survey. CONCLUSION: Approximately 60% of the ventilated patients with COVID-19 experienced persistent PICS, especially delirium, and required longer mechanical ventilation.

Neurological outcomes after extracorporeal cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest: a retrospective observational study in a rural tertiary care center.

BACKGROUND: In a rural region with few medical resources, we have promoted the strategy that if an out-of-hospital cardiac arrest (OHCA) patient is likely reversible, he or she should be transported directly from the scene of cardiac arrest to the only tertiary care center where extracorporeal cardiopulmonary resuscitation (ECPR) is readily available. We investigated 1-month survival and neurological outcomes after ECPR in OHCA patients at this center. METHODS: We implemented a retrospective review of OHCA patients of heterogeneous origin in whom ECPR was performed. Demographic characteristics, cardiopulmonary resuscitation, ECPR details, and neurological outcomes were evaluated. Cerebral performance categories were used to assign each patient to favorable or unfavorable outcome groups. RESULTS: Fifty OHCA patients underwent ECPR. Presumed causes of OHCA were cardiac etiology in 32 patients, accidental hypothermia in 7 patients, and other causes in 11 patients. Overall, 13 patients (26%) survived and 10 patients (20%) had favorable outcomes. Of the 32 patients with OHCA of cardiac origin, 5 patients (16%) had favorable outcomes. Of the seven patients with OHCA of hypothermic origin, five patients (71%) had favorable outcomes. No clinically reliable predictors to identify ECPR candidates were found. However, all nine OHCA patients over 70 years of age had unfavorable outcomes (P = 0.224). In addition, all seven patients who satisfied the basic life support termination-of-resuscitation rule had unfavorable outcomes (P = 0.319). CONCLUSIONS: ECPR can be a useful means to rescue OHCA patients who are unresponsive to conventional cardiopulmonary resuscitation in a rural tertiary care center, in a manner similar to that observed in the urban regions.

Incidence and mortality of acute myocardial infarction. A population-based study including patients with out-of-hospital cardiac arrest.

The in-hospital mortality rate of acute myocardial infarction (AMI) is improving. In Japan, little information exists concerning the incidence and mortality of AMI. Therefore, our population-based analysis examined the incidence and mortality rate in AMI cases in individuals that lived in the Matsumoto region in 2002. We studied 169 AMI patients who were admitted within 14 days after a non-out-of-hospital cardiac arrest (non-OHCA group) and 63 patients with an AMI-related out-of-hospital cardiac arrest (OHCA group). The in-hospital mortality rate of the non-OHCA group was 9.5% (reperfusion therapy [+] 3.4%, [-] 22.7%, P < 0.0001). The rate of return of spontaneous circulation and the survival rate were 21% and 1.6%, respectively, in the OHCA group. The incidence of AMI in the non-OHCA and OHCA groups combined was 55.2 to 63.1 events/100,000 people annually and the mean age of AMI patients was 70 ± 13 years. The population-based mortality rate of AMI was 34% to 42%. The mortality rate of AMI remains high, and most deaths occur outside of the hospital. Prehospital care may lower the mortality rate of AMI.

Protocol-based noninvasive positive pressure ventilation for acute respiratory failure.

PURPOSE: Noninvasive positive pressure ventilation (NPPV) has been suggested to be associated with adverse outcomes in emergency patients with acute respiratory failure (ARF), possibly because of a delay in tracheal intubation (TI). We hypothesized that protocol-based NPPV (pNPPV) might improve the outcomes, compared with individual physician-directed NPPV (iNPPV). METHODS: To guide decision making regarding the use of NPPV, we developed an NPPV protocol. Observational data were collected before and after protocol implementation in consecutive patients with ARF and compared between the pNPPV and the iNPPV groups. RESULTS: The results for pNPPV (n = 37) were compared with those for iNPPV (n = 37). No significant baseline differences in patient characteristics were observed between the two groups except for mean age, which was higher in the pNPPV group than in the iNPPV group (P = 0.02). Rate of TI and duration of mechanical ventilation were similar in the two groups. However, the time from the start of NPPV until TI tended to be shorter in the pNPPV group than in the iNPPV group (P = 0.11). The hospital mortality rate was significantly lower in the pNPPV group than in the iNPPV group (P = 0.049). Although the length of hospital stay was shorter in the pNPPV group than in the iNPPV group, this trend did not reach statistical significance (P = 0.14). CONCLUSIONS: The present study suggests that pNPPV is effective and likely to improve the mortality rate of emergency patients with ARF.

Painless acute aortic dissection. - Diagnostic, prognostic and clinical implications.-.

BACKGROUND: Acute aortic dissection (AAD) classically presents as sudden, severe chest, back, or abdominal pain. However, there have been several documented cases presenting with atypical features. The clinical characteristics and outcomes of patients with painless AAD were investigated. METHODS AND RESULTS: The study group comprised 98 patients (53 males, 45 females; 66 ± 12 years) with AAD admitted to hospital from 2002 to 2007: 16 patients (17%) had no pain (painless group) and 82 patients had pain (painful group). In 81% of the painless group and 70% of the painful group there was a type A dissection. The painless group more frequently had a persistent disturbance of consciousness (44% vs. 6%, P < 0.001), syncope (25% vs. 1%, P < 0.001) and a focal neurologic deficit (19% vs. 2%, P = 0.006) as presenting symptoms. Imaging study findings were not significantly different. Cerebral ischemia (50% vs. 1%, P < 0.001) and cardiac tamponade (38% vs. 13%, P = 0.01) were more frequent complications in the painless group. In-hospital mortality was not significantly different (19% vs. 15%). However, the painless group had a more unfavorable functional outcome on overall performance category (P < 0.001). CONCLUSIONS: Painless AAD may be more frequent than previously reported. Painless AAD patients often present with a disturbance of consciousness or a neurologic deficit, and have a higher morbidity than painful AAD patients.

Traumatic middle cerebral artery aneurysm: case report and review of the literature.

Traumatic intracranial aneurysms are rare. A case of traumatic middle cerebral artery aneurysm was presented. A 66-year-old man sustained a severe head injury in a bicycle accident. Serial computed tomography and angiography showed the delayed intracerebral hemorrhage caused by the traumatic middle cerebral artery aneurysm. The aneurysm was trapped and removed. Histological examination clearly revealed the pseudoaneurysm. Traumatic middle cerebral aneurysms were reviewed.

Subtle computed tomography abnormalities in cerebral deep sinus thrombosis.

A patient with cerebral deep sinus thrombosis, which was not diagnosed on the first examination, is reported. A 46-year-old woman presented with headache and vomiting. Neurological examination and a brain computed tomography (CT) scan showed no obvious abnormal findings. The patient suffered disturbed consciousness on the day after the examination, and was admitted to our emergency centre. A CT scan and magnetic resonance imaging revealed an ischaemic lesion in the left basal ganglia, suggesting deep sinus occlusion. Anticoagulant therapy was administered. One day after admission, a CT scan showed a haematoma and severe brain swelling in the same region. Cerebral angiography demonstrated a straight sinus occlusion. Intracranial pressure was not controlled with hypothermia, and the patient died 25 days after admission. Review of the initial CT scan revealed subtle, early findings of deep venous thrombosis that were missed on first examination.

Description and first clinical application of AirWay Scope for tracheal intubation.

We have developed a novel airway apparatus, AirWay Scope, which we have used in the orotracheal intubation of 10 consecutive patients requiring general anesthesia before neurosurgical procedures. The characteristic shape of the introducer (INTLOCK), the tube guiding function and the sighting device of the AirWay Scope has possibility to facilitate tracheal intubation. Here, we report the first clinical application of this system and describe potential advantages of the apparatus.

Incomplete ventricular septal rupture following blunt chest trauma--a case report.

This report describes a case of traumatic incomplete rupture of the ventricular septum, a rare complication caused by blunt chest trauma. Although a serial ECG progressed its course similar to acute anteroseptal myocardial infarction in this case, there was little clinical clue of septal tear. The diagnosis was established by transthoracic echocardiography. The authors chose a conservative line of management rather than surgical repair for incomplete septal rupture because of the patent's stable clinical course and hemodynamic status. A sequence of echocardiography during a 32-day stay in the hospital showed no change in the extent of incomplete septal rupture, septal structure, systolic function, and shape of left ventricle and also obtained no evidence of shunting through the rupture. In conclusion, echocardiography is a useful investigation to make a diagnosis as well as for follow-up in case of incomplete ventricular septal rupture. A close follow-up of incomplete septal rupture with serial echocardiography should be performed, because several cases of delayed ventricular septal rupture following blunt chest trauma have been reported.

Continuous suction method in superficial temporal artery-middle cerebral artery anastomosis surgery. Technical note.

A new method was developed to maintain a bloodless microscopic operative field for superficial temporal artery-middle cerebral artery (MCA) anastomosis surgery. A silicone suction tube with multiple holes is placed circumferentially under the reflected dural flaps around the craniotomy. Blood and irrigated saline are continuously aspirated by the tube. Use of this method in nine patients significantly reduced the mean MCA trapping time (24.0 +/- 2.8 min) compared with nine patients treated using the conventional method (30.1 +/- 4.6 min). MCA trapping time is shortened because the surgery is not interrupted for manual suctioning of bloody cerebrospinal fluid.

Middle cerebral artery occlusion associated with acute myocardial infarction in the perioperative period--case report.

A 68-year-old woman with no history of cardiac events suffered acute myocardial infarction after surgery for middle cerebral artery (MCA) occlusion manifesting as transient left motor weakness. Diffusion-weighted magnetic resonance imaging revealed multiple infarctions in the right cerebral hemisphere. Magnetic resonance angiography and cerebral angiography demonstrated an occlusion at the horizontal segment of the right MCA and no collateral circulation. Cerebral blood flow study 6 weeks after the initial presentation indicated decreased blood flow in the right cerebral hemisphere. Superficial temporal artery-MCA anastomosis was conducted to prevent recurrent cerebral infarction. Two hours after surgery, her systolic blood pressure fell to 60 mmHg and her consciousness worsened. Emergency coronary angiography indicated occlusion of the right coronary artery. Percutaneous coronary intervention was successfully performed and the subsequent course was uneventful. Preoperative evaluation of the coronary artery may be necessary before surgery for cerebral ischemic disease in both the intracranial and extracranial arteries.

A saccular-like dissecting aneurysm of the anterior cerebral artery that developed 2 years after an ischemic event.

BACKGROUND: A rare case of a growing dissecting aneurysm, which was located at the horizontal (A1) segment of the anterior cerebral artery (ACA), is reported. CASE DESCRIPTION: A 53-year-old woman experienced left hemiparesis and alien hand syndrome. A computerized tomography scan showed an infarction in the right frontal lobe, and cerebral angiography revealed a false lumen and intimal flap at the A1 segment of the ACA. Magnetic resonance angiography demonstrated that the stenosis progressed 6 months later and improved 1 year later. Cerebral angiography showed a saccular-like aneurysm 2 years later. The surgery was planned for prevention of aneurysmal rupture. The aneurysm, which was cocoon shaped, was exposed surgically and was resected. Histological examination of the aneurysm showed arterial dissection. The postoperative course was uneventful without additional neurological deficits. CONCLUSION: This is the first case report of A1 dissecting aneurysm presenting with an ischemic event in the literature. The sequential change of the configuration was curious to develop aneurysmal dilatation in 2 years. Long-term follow-up is necessary even after disappearance of the arterial dissection.

Harvesting blood stem cells from cranial bone at craniotomy--a preliminary study.

Primary brain tumors seldom infiltrate into the cranium, even if they are invasive in the central nervous system. In this study, we examined whether blood stem cells can be harvested from cranial bone at craniotomy. Bone marrow cells in cranial bone were counted in 181 craniotomy specimens after staining with hematoxylin and eosin. Marrow volume was measured in 37 specimens using three-dimensional computed tomography (CT). In 10 cases, viable cells collected from very small bone pieces at craniotomy were cultured to examine granulocyte/macrophage colony-forming units (CFU-GM). In 2 cases, bone marrow cells were practically harvested from removed bone at surgery. The weight of bone flap at craniotomy was 35.0 +/- 18.0 g. Bone flap marrow contained 1.5 x 10(9) cells/ml. CT examination showed that bone flap volume was 35.0 +/- 9.0 ml and marrow ratio was 65.1 +/- 13.5%. Thus, at craniotomy, a typical bone flap contained about 3.4 x 10(10) cells. Bone marrow cell count gradually decreased as subject age increased. The bone pieces obtained at craniotomy contained 3.1 +/- 3.4 x 10(6) cells/g, and CFU-GM count was 0.4 x 10(5) cells/g. In one case, we collected 3.4 x 10(8) cells, including 1.8 x 10(6) CFU-GM colonies. In another case, we collected 9.7 x 10(8) cells, including 4.8 x 10(6) CFU-GM colonies. These findings indicate that, at craniotomy, the number of blood stem cells in a typical bone flap is sufficient for autologous blood stem cell rescue.

Malignant astrocytoma of the conus medullaris treated by spinal cordectomy.

We present a case of malignant astrocytoma of the conus medullaris in a 48-year-old man treated by spinal cordectomy. Preoperative examination revealed a tumor at the T12 to L1 level, and intraparenchymal invasion up to T8. The spinal cord was amputated caudally to the root entry zones of the T9 sensory roots. Additional cordectomies were repeated three times because of tumor infiltration at the cut end. At each procedure, the cord was segmentally transected just caudal to the root entry zones of the p reserving-aid sensory roots to minimize the neural deficit. The final transected level was between T3 and T4, and the cut end did not pathologically reveal any tumor invasion. However, the patient died from tumor recurrence and dissemination. Although the attempt to control the tumor by long segment cordectomy was unsuccessful, spinal cordectomy with wide margin may be a possible treatment for patients with malignant astrocytoma of the conus medullaris presenting with complete deficit below the lesion a nd no dissemination, if in an early stage.

Aneurysm originating from the fenestration of the posterior cerebral artery: case report.

OBJECTIVE AND IMPORTANCE: A rare case of an aneurysm arising at the fenestration of the P2 segment of the posterior cerebral artery is reported. CLINICAL PRESENTATION: A 37-year-old man presented with severe headache and disturbance of consciousness. Computed tomographic scanning showed diffuse subarachnoid hemorrhage. Cerebral angiography revealed an aneurysm at the fenestration of the P2 segment of the right posterior cerebral artery. The aneurysm was located at the middle portion of the lower trunk of the fenestration. An unruptured arteriovenous malformation was incidentally found in the right thalamus. INTERVENTION: A right frontotemporal craniotomy with orbitozygomatic osteotomy was made, and the aneurysm was successfully clipped. One year after the operation, gamma knife surgery was performed for the right thalamic arteriovenous malformation. CONCLUSION: This is the first reported case of an aneurysm originating from the middle portion of a fenestrated posterior cerebral artery.