Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AoA), British Society of Orthopaedic Anaesthetists (BSOA), Intensive Care Society (ICS), Neuro Anaesthesia and Critical Care Society (NACCS), Faculty of Prehospital Care and Royal College of Emergency Medicine (RCEM).

BACKGROUND: There are concerns that airway management in patients with suspected or confirmed cervical spine injury may exacerbate an existing neurological deficit, cause a new spinal cord injury or be hazardous due to precautions to avoid neurological injury. However, there are no evidence-based guidelines for practicing clinicians to support safe and effective airway management in this setting. METHODS: An expert multidisciplinary, multi-society working party conducted a systematic review of contemporary literature (January 2012-June 2022), followed by a three-round Delphi process to produce guidelines to improve airway management for patients with suspected or confirmed cervical spine injury. RESULTS: We included 67 articles in the systematic review, and successfully agreed 23 recommendations. Evidence supporting recommendations was generally modest, and only one moderate and two strong recommendations were made. Overall, recommendations highlight key principles and techniques for pre-oxygenation and facemask ventilation; supraglottic airway device use; tracheal intubation; adjuncts during tracheal intubation; cricoid force and external laryngeal manipulation; emergency front-of-neck airway access; awake tracheal intubation; and cervical spine immobilisation. We also signpost to recommendations on pre-hospital care, military settings and principles in human factors. CONCLUSIONS: It is hoped that the pragmatic approach to airway management made within these guidelines will improve the safety and efficacy of airway management in adult patients with suspected or confirmed cervical spine injury.

Effects of the COVID-19 Pandemic on Everyday Neurosurgical Practice in Alsace, France: Lessons Learned, Current Perspectives, and Future Challenges-Preliminary Results of a Longitudinal Multicentric Study Registry.

Background and Objectives: The global outbreak caused by the SARS-CoV-2 pandemic disrupted healthcare worldwide, impacting the organization of intensive care units and surgical care units. This study aimed to document the daily neurosurgical activity in Alsace, France, one of the European epicenters of the pandemic, and provide evidence of the adaptive strategies deployed during such a critical time for healthcare services. Materials and Methods: The multicentric longitudinal study was based on a prospective cohort of patients requiring neurosurgical care in the Neurosurgical Departments of Alsace, France, between March 2020 and March 2022. Surgical activity was compared with pre-pandemic performances through data obtained from electronic patient records. Results: A total of 3842 patients benefited from care in a neurosurgical unit during the period of interest; 2352 of them underwent surgeries with a wide range of pathologies treated. Surgeries were initially limited to neurosurgical emergencies only, then urgent cases were slowly reinstated; however, a significant drop in surgical volume and case mix was noticed during lockdown (March-May 2020). The crisis continued to impact surgical activity until March 2022; functional procedures were postponed, though some spine surgeries could progressively be performed starting in October 2021. Various social factors, such as increased alcohol consumption during the pandemic, influenced the severity of traumatic pathologies. The progressive return to the usual profile of surgical activity was characterized by a rebound of oncological interventions. Deferrable procedures for elective spinal and functional pathologies were the most affected, with unexpected medical and social impacts. Conclusions: The task shifting and task sharing approaches implemented during the first wave of the pandemic supported the reorganization of neurosurgical care in its aftermath and enabled the safe and timely execution of a broad spectrum of surgeries. Despite the substantial disruption to routine practices, marked by a significant reduction in elective surgical volumes, comprehensive records demonstrate the successful management of the full range of neurosurgical pathologies. This underscores the efficacy of adaptive strategies in navigating the challenges imposed by the largest healthcare crisis in recent history. Those lessons will continue to provide valuable insights and guidance for health and care managers to prepare for future unpredictable scenarios.

Cardiac abnormalities identified with echocardiography in anorexia nervosa: systematic review and meta-analysis.

BACKGROUND: Anorexia nervosa affects most organ systems, with 80% suffering from cardiovascular complications. AIMS: To define echocardiographic abnormalities in anorexia nervosa through systematic review and meta-analysis. METHOD: Two reviewers independently assessed eligibility of publications from Medline, EMBASE and Cochrane Database of Systematic Reviews registries. Studies were included if anorexia nervosa was the primary eating disorder and the main clinical association in described cardiac abnormalities. Data was extracted in duplicate and quality-assessed with a modified Newcastle-Ottawa scale. For continuous outcomes we calculated mean and standardised mean difference (SMD), and corresponding 95% confidence interval. For dichotomous outcomes we calculated proportion and corresponding 95% confidence interval. For qualitative data we summarised the studies. RESULTS: We identified 23 eligible studies totalling 960 patients, with a mean age of 17 years and mean body mass index of 15.2 kg/m2. Fourteen studies (469 participants) reported data suitable for meta-analysis. Cardiac abnormalities seen in anorexia nervosa compared with healthy controls were reduced left ventricular mass (SMD 1.82, 95% CI 1.32-2.31, P < 0.001), reduced cardiac output (SMD 1.92, 95% CI 1.38-2.45, P < 0.001), increased E/A ratio (SMD -1.10, 95% CI -1.67 to -0.54, P < 0.001), and increased incidence of pericardial effusions (25% of patients, P < 0.01, 95% CI 17-34%, I2 = 80%). Trends toward improvement were seen with weight restoration. CONCLUSIONS: Patients with anorexia nervosa have structural and functional cardiac changes, identifiable with echocardiography. Further work should determine whether echocardiography can help stratify severity and guide safe patient location, management and effectiveness of nutritional rehabilitation.

Educational initiatives for electroencephalography in the critical care setting: a systematic review and meta-analysis.

PURPOSE: We systematically reviewed existing critical care electroencephalography (EEG) educational programs for non-neurologists, with the primary goal of reporting the content covered, methods of instruction, overall duration, and participant experience. Our secondary goals were to assess the impact of EEG programs on participants' core knowledge, and the agreement between non-experts and experts for seizure identification. SOURCE: Major databases were searched from inception to 30 August 2020. Randomized controlled trials, cohort studies, and descriptive studies were all considered if they reported an EEG curriculum for non-neurologists in a critical care setting. Data were presented thematically for the qualitative primary outcome and a meta-analysis using a random effects model was performed for the quantitative secondary outcomes. PRINCIPAL FINDINGS: Twenty-nine studies were included after reviewing 7,486 citations. Twenty-two studies were single centre, 17 were from North America, and 16 were published after 2016. Most EEG studies were targeted to critical care nurses (17 studies), focused on processed forms of EEG with amplitude-integrated EEG being the most common (15 studies), and were shorter than one day in duration (24 studies). In pre-post studies, EEG programs significantly improved participants' knowledge of tested material (standardized mean change, 1.79; 95% confidence interval [CI], 0.86 to 2.73). Agreement for seizure identification between non-experts and experts was moderate (Cohen's kappa = 0.44; 95% CI, 0.27 to 0.60). CONCLUSIONS: It is feasible to teach basic EEG to participants in critical care settings from different clinical backgrounds, including physicians and nurses. Brief training programs can enable bedside providers to recognize high-yield abnormalities such as non-convulsive seizures.

RéSUMé: OBJECTIF: Nous avons réalisé une revue systématique des programmes éducatifs d'électroencéphalographie (EEG) en soins intensifs s'adressant aux non-neurologues, avec pour but principal de rapporter le contenu couvert, les méthodes d'enseignement, la durée globale et l'expérience des participants. Nos objectifs secondaires étaient d'évaluer l'impact des programmes d'EEG sur les connaissances de base des participants, et l'accord entre non-experts et experts pour l'identification des convulsions. MéTHODE: Les principales bases de données ont été consultées depuis leur création jusqu'au 30 août 2020. Les études randomisées contrôlées, les études de cohorte et les études descriptives ont toutes été prises en compte si elles décrivaient un programme de formation en EEG pour les non-neurologues en milieu de soins intensifs. Les données ont été présentées thématiquement en ce qui touchait notre critère d'évaluation principal qualitatif, et une méta-analyse utilisant un modèle à effets aléatoires a été exécutée pour les critères secondaires quantitatifs. CONSTATATIONS PRINCIPALES: Vingt-neuf études ont été incluses après avoir examiné 7486 citations. Vingt-deux études étaient monocentriques, 17 provenaient d'Amérique du Nord et 16 avaient été publiées après 2016. La plupart des études sur l'EEG visaient le personnel infirmier en soins intensifs (17 études); elles se concentraient sur les formes analysées d'EEG; l'EEG à amplitude intégrée était le thème le plus fréquemment abordé (15 études), et la plupart duraient moins d'un jour (24 études). Dans les études avant-après, les programmes d'EEG ont considérablement amélioré les connaissances des participants du matériel testé (changement moyen normalisé, 1,79; intervalle de confiance [IC] à 95 %, 0,86 à 2,73). L'accord en matière d''identification des convulsions entre non-experts et experts était modéré (kappa de Cohen = 0,44; IC 95 %, 0,27 à 0,60). CONCLUSION: Il est possible d'enseigner l'EEG de base dans des milieux de soins intensifs à des participants provenant de différents milieux cliniques, y compris les médecins et le personnel infirmier. De brefs programmes de formation peuvent permettre aux fournisseurs de soins au chevet de reconnaître les anomalies à haut impact comme par exemple des crises épileptiques non convulsives.

Mismatch between Tissue Partial Oxygen Pressure and Near-Infrared Spectroscopy Neuromonitoring of Tissue Respiration in Acute Brain Trauma: The Rationale for Implementing a Multimodal Monitoring Strategy.

The brain tissue partial oxygen pressure (PbtO2) and near-infrared spectroscopy (NIRS) neuromonitoring are frequently compared in the management of acute moderate and severe traumatic brain injury patients; however, the relationship between their respective output parameters flows from the complex pathogenesis of tissue respiration after brain trauma. NIRS neuromonitoring overcomes certain limitations related to the heterogeneity of the pathology across the brain that cannot be adequately addressed by local-sample invasive neuromonitoring (e.g., PbtO2 neuromonitoring, microdialysis), and it allows clinicians to assess parameters that cannot otherwise be scanned. The anatomical co-registration of an NIRS signal with axial imaging (e.g., computerized tomography scan) enhances the optical signal, which can be changed by the anatomy of the lesions and the significance of the radiological assessment. These arguments led us to conclude that rather than aiming to substitute PbtO2 with tissue saturation, multiple types of NIRS should be included via multimodal systemic- and neuro-monitoring, whose values then are incorporated into biosignatures linked to patient status and prognosis. Discussion on the abnormalities in tissue respiration due to brain trauma and how they affect the PbtO2 and NIRS neuromonitoring is given.

Criteria for Intensive Care admission and monitoring after elective craniotomy.

PURPOSE OF REVIEW: The current article revises the recent evidence on ICU admission criteria and postoperative neuromonitoring for patients undergoing elective craniotomy. RECENT FINDINGS: Only a small proportion of elective postoperative neurosurgical patients require specific medical interventions and invasive monitoring. Among these, patients undergoing elective craniotomy are frequently admitted to neuro-ICU, specialist postanaesthesia care units or intermediate-level care unit in the postoperative period.Craniotomy patients have a high risk of neurological complications in the immediate postoperative period and might require advanced neuromonitoring, especially if sedation is continued in the ICU.Furthermore, the concept of enhanced recovery after surgery with the goal of improving functional capacity after surgery and decreasing morbidity has expanded to encompass neurosurgery.Postoperative clinical examination and neurological scores, bispectral index and simplified electroencephalography, and morning discharge huddles are the most used strategies in this context. SUMMARY: After elective craniotomy, ICU admission should be warranted to patients who show new neurological deficits, especially when these include reduced consciousness or deficits of the lower cranial nerves, or have surgical indication for delayed extubation. Currently, evidence does not allow defining standardized protocol to guide ICU admission and postoperative neuromonitoring.

Enhancing contrast agents and radiotracers performance through hyaluronic acid-coating in neuroradiology and nuclear medicine.

The use of hyaluronic acid nanoshells has been proposed to encapsulate prodrugs and exploit the mechanisms of interactions between living cells, like endocytes or cancer cells and hyaluronic acid, which is a natural component of the extracellular matrix. In this review we describe the potential and the limits of this promising research trend and discuss the theoretical advantages of such an engineering approach. Is it a possible scalability to increase the efficacy and biodegradability of molecules like contrast media and radiotracers especially for neuroradiology and nuclear medicine studies.

Syndrome of trephined-underestimated and poorly understood complication after decompressive craniectomy.

Decompressive craniectomy (DC) is still a matter of debate, with a numerous complications as expansion of haemorrhagic contusions, external cerebral herniation, subdural hygromas, post-traumatic hydrocephalus (HC). The often overlooked "syndrome of the trephined" (ST) as a delayed complication of DC also known as sinking skin flap sy initially described in 1939.ST is characterised by the neurological changes associated with alteration of the pressure/volume relationship between intracranial pressure (ICP), volume of cerebrospinal fluid (CSF), blood, and brain tissue in patients with large bone defects. This review aims at elucidating the mechanisms responsible for the development of ST, and providing useful tips and red-flag signs for healthcare professionals involved with care of post DC patients. Symptoms identified on time could help to develop appropriate treatment strategies for this suddenly deteriorating, but possible reversible condition. Although the treatment strategy is straightforward, calling for a prompt cranioplasty, the correction of HC through CSF diversion devices might require a lengthy optimisation period. Continuous changes in the setting of the shunting systems or spinal tap might lead to dangerous swinging of the midline structures causing further neurological deterioration. Thus, finding the right balance in terms of clinical management often represents a significant challenge.

To wake-up, or not to wake-up: that is the Hamletic neurocritical care question!

The need for a reliable neurological evaluation in severely brain-injured patients conflicts with sedation, which is routinely administered. Helbok and colleagues prospectively evaluated in a small cohort of 20 sedated severely brain-injured patients the effects of a wakeup test on intracranial pressure (ICP), brain tissue oxygen tension and brain metabolism. The test has been considered potentially risky on 34% of the study days. When the test is performed, ICP and cerebral perfusion pressure increase, usually slightly, except in a subgroup of patients with lower cerebral compliance where marked ICP and cerebral perfusion pressure changes were recorded. In this cohort, the information gained with the wake-up test has been negligible. Given the current little knowledge about the benefits of interruption of continuous sedation in brain-injured patients, it is extremely important to adopt multiple monitoring modalities in neurocritical care in order to escape wake-up tests in those patients who will potentially be harmed by this procedure. Once the clinical condition will improve, sedation needs to be tapered and suspended as soon as possible.

High altitude induced bilateral non-traumatic subdural hematoma.

BACKGROUND: Minor clinical complaints such as headache and drowsiness after a disco party with alcohol abuse may be an unlikely cause for neurological consultation, but, rarely, they may hide a challenging diagnosis. CASE REPORT: A young male patient admitted to our Neurosurgical Department for progressive headache showed a sudden clinical deterioration of consciousness; head CT scan was promptly obtained and thick bilateral subdural hematomas requiring urgent craniotomies and drainage were detected. While his anamnesis was surprisingly negative for head trauma, coagulopathies, or other common causes of subdural hematoma, he reported a curious history of 10-d onset of symptoms after a farewell disco party on a high-altitude location, almost 9000 ft (>2700 m) above mean sea level, followed by an intercontinental flight back to his seaside hometown. Following surgery the patient eventually experienced a rapid recovery from this frightening experience. DISCUSSION: Due to its uniqueness, the case is reported and the influence of possible provoking causes relevant in the pathogenesis of subdural hematomas is carefully outlined.

Postoperative granulomas versus tumor recurrence: PET and SPET scans as strategic adjuvant tools to conventional neuroradiology.

A mandatory differential diagnosis between postoperative granulomas and tumor recurrence is required whenever space-occupying lesions are detected at the surgical site, few months after removal of the intracranial neoplasm, because these two pathologies can often mimic each other clinically, by imaging techniques and even macroscopically. Since history or signs of inflammation may be lacking, and neurological complaints are generally nonspecific, a thorough imaging investigation is usually the only way to diagnosis. Herein we discuss the pathological basis and timing of granuloma formation along with the imaging characteristics and nuclear medicine findings necessary to confirm or exclude the diagnosis of tumor recurrence. In conclusion, the high sensitivity of positron emission tomography and the wide availability of single photon emission tomography can identify certain parameters (isometabolism, uptake in macrophages, etc.) to support differential diagnosis between postoperative granulomas and tumor recurrence.

Comparison of the Asleep-Awake-Asleep Technique and Monitored Anesthesia Care During Awake Craniotomy: A Systematic Review and Meta-analysis.

Awake craniotomy (AC) is the preferred surgical option for intractable epilepsy and resection of tumors adjacent to or within eloquent cortical areas. Monitored anesthesia care (MAC) or an asleep-awake-asleep (SAS) technique is most widely used during AC. We used a random-effects modeled meta-analysis to synthesize the most recent evidence to determine whether MAC or SAS is safer and more effective for AC. We included randomized controlled trials and observational studies that explored the incidence of AC failure, duration of surgery, and hospital length of stay in adult patients undergoing AC. Eighteen studies were included in the final analysis. MAC was associated with a lower risk of AC failure when compared with SAS (global pooled proportion MAC vs. SAS 1% vs. 4%; odds ratio [ORs]: 0.28; 95% confidence interval [CI]: 0.11-0.71; P=0.007) and shorter surgical procedure time (global pooled mean MAC vs. SAS 224.44 vs. 327.94 min; mean difference, -48.76 min; 95% CI: -61.55 to -35.97; P<0.00001). SAS was associated with fewer intraoperative seizures (global pooled proportion MAC vs. SAS 10% vs. 4%; OR: 2.38; 95% CI: 1.05-5.39; P=0.04). There were no differences in intraoperative nausea and vomiting between the techniques (global pooled proportion MAC vs. SAS: 4% vs. 8%; OR: 0.86; 95% CI: 0.30-2.45; P=0.78). Length of stay was shorter in the MAC group (MAC vs. SAS 3.96 vs. 6.75 days; mean difference, -1.30; 95% CI: -2.69 to 0.10; P=0.07). In summary, MAC was associated with lower AC failure rates and shorter procedure time compared with SAS, whereas SAS was associated with a lower incidence of intraoperative seizures. However, there was a high risk of bias and other limitations in the studies included in this review, so the superiority of 1 technique over the other needs to be confirmed in larger randomized studies.

A scoping review on the challenges, improvement programs, and relevant output metrics for neurotrauma services in major trauma centers.

Background: For a neurotrauma unit to be defined as a structured neurotrauma service (NS) the following criteria must be satisfied: A dedicated neurointensive care unit, endovascular neuroradiology, in-hospital neurorehabilitation unit and helicopter platform within the context of a Level I trauma center. Designing an effective NS can be challenging, particularly when considering the different priorities and resources of countries across the globe. In addition the impact on clinical outcomes is not clearly established. Methods: A scoping review of the literature spanning from 2000 to 2020 meant to identify protocols, guidelines, and best practices for the management of traumatic brain injury (TBI) in NS was conducted on the US National Library of Medicine and National Institute of Health databases. Results: Limited evidence is available regarding quantitative and qualitative metrics to assess the impact of NSs and specialist follow-up clinics on patients' outcome. Of note, the available literature used to lack detailed reports for: (a) Geographical clusters, such as low-to-middle income countries (LMIC); (b) clinical subgroups, such as mild TBI; and (c) long-term management, such as rehabilitation services. Only in the last few years more attention has been paid to those research topics. Conclusion: NSs can positively impact the management of the broad spectrum of TBI in different clinical settings; however more research on patients' outcomes and quality of life metrics is needed to establish their efficacy. The collaboration of global clinicians and the development of international guidelines applicable also to LMIC are warranted.

Early Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage Is Associated with Prior Global Cerebral Hypoperfusion.

BACKGROUND AND PURPOSE: Early cerebral infarction (ECI) is an independent factor associated with poor outcome following aneurysmal subarachnoid hemorrhage (aSAH). We aimed to test the association between ECI and prior global impairment of cerebral perfusion. METHODS: We performed a retrospective cohort study of consecutive patients admitted for aSAH in 2 centers. ECI was defined as any radiological cerebral infarction identified within 3 days from the onset of bleeding and not related to aneurysm repair. Global impairment of cerebral perfusion was defined as clinical or transcranial Doppler signs of brain hypoperfusion together with circulatory failure or intracranial hypertension in keeping with guidelines. The association between ECI and prior occurrence of global impairment of cerebral perfusion was tested using binary logistic regression adjusted for confounders identified in the univariate analysis. RESULTS: Seven hundred fifty-three patients with aSAH were included. ECI was observed in 40 patients (5.3%; 95% CI = 3.7%-6.9%). Prior global impairment of cerebral perfusion occurred in 90% of them (60% in-hospital) versus in 11% of patients without ECI (P < 0.001). In the multivariate analysis, World Federation of Neurological Surgeons grade (OR = 2.3, 95% CI = 1.5-3.6, P<0.001), global impairment of cerebral perfusion due to circulatory failure (OR = 4.7, 95% CI = 1.8-11, P = 0.001), or intracranial hypertension (OR = 11.1, 95% CI = 3.8-32.3, P<0.001) was an independent risk factor for ECI. CONCLUSIONS: Our study demonstrated that ECI is strongly associated with the prior occurrence of global impairment of cerebral perfusion, independent of World Federation of Neurological Surgeons grade. These patients may benefit from more intensive and systematic prevention of impaired cerebral perfusion, particularly in poor-grade patients.

Toxicology of Psychoactive Substances.

A trend in the increasing use of prescription psychoactive drugs (PADs), including antidepressants, antipsychotics, and mood stabilizers, has been reported in the United States and globally. In addition, there has been an increase in the production and usage of illicit PADs and emergence of new psychoactive substances (NPSs) all over the world. PADs pose unique challenges for critical care providers who may encounter toxicology issues due to drug interactions, side effects, or drug overdoses. This article provides a summary of the toxicologic features of commonly used and abused PADs: antidepressants, antipsychotics, mood stabilizers, hallucinogens, NPSs, caffeine, nicotine, and cannabis.

Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study.

BACKGROUND: The indications for intracranial pressure (ICP) monitoring in patients with acute brain injury and the effects of ICP on patients' outcomes are uncertain. The aims of this study were to describe current ICP monitoring practises for patients with acute brain injury at centres around the world and to assess variations in indications for ICP monitoring and interventions, and their association with long-term patient outcomes. METHODS: We did a prospective, observational cohort study at 146 intensive care units (ICUs) in 42 countries. We assessed for eligibility all patients aged 18 years or older who were admitted to the ICU with either acute brain injury due to primary haemorrhagic stroke (including intracranial haemorrhage or subarachnoid haemorrhage) or traumatic brain injury. We included patients with altered levels of consciousness at ICU admission or within the first 48 h after the brain injury, as defined by the Glasgow Coma Scale (GCS) eye response score of 1 (no eye opening) and a GCS motor response score of at least 5 (not obeying commands). Patients not admitted to the ICU or with other forms of acute brain injury were excluded from the study. Between-centre differences in use of ICP monitoring were quantified by using the median odds ratio (MOR). We used the therapy intensity level (TIL) to quantify practice variations in ICP interventions. Primary endpoints were 6 month mortality and 6 month Glasgow Outcome Scale Extended (GOSE) score. A propensity score method with inverse probability of treatment weighting was used to estimate the association between use of ICP monitoring and these 6 month outcomes, independently of measured baseline covariates. This study is registered with ClinicalTrial.gov, NCT03257904. FINDINGS: Between March 15, 2018, and April 30, 2019, 4776 patients were assessed for eligibility and 2395 patients were included in the study, including 1287 (54%) with traumatic brain injury, 587 (25%) with intracranial haemorrhage, and 521 (22%) with subarachnoid haemorrhage. The median age of patients was 55 years (IQR 39-69) and 1567 (65%) patients were male. Considerable variability was recorded in the use of ICP monitoring across centres (MOR 4·5, 95% CI 3·8-4·9 between two randomly selected centres for patients with similar covariates). 6 month mortality was lower in patients who had ICP monitoring (441/1318 [34%]) than in those who were not monitored (517/1049 [49%]; p<0·0001). ICP monitoring was associated with significantly lower 6 month mortality in patients with at least one unreactive pupil (hazard ratio [HR] 0·35, 95% CI 0·26-0·47; p<0·0001), and better neurological outcome at 6 months (odds ratio 0·38, 95% CI 0·26-0·56; p=0·0025). Median TIL was higher in patients with ICP monitoring (9 [IQR 7-12]) than in those who were not monitored (5 [3-8]; p<0·0001) and an increment of one point in TIL was associated with a reduction in mortality (HR 0·94, 95% CI 0·91-0·98; p=0·0011). INTERPRETATION: The use of ICP monitoring and ICP management varies greatly across centres and countries. The use of ICP monitoring might be associated with a more intensive therapeutic approach and with lower 6-month mortality in more severe cases. Intracranial hypertension treatment guided by monitoring might be considered in severe cases due to the potential associated improvement in long-term clinical results. FUNDING: University of Milano-Bicocca and the European Society of Intensive Care Medicine.

Educational initiatives and implementation of electroencephalography into the acute care environment: a protocol of a systematic review.

BACKGROUND: Use of electroencephalography (EEG) is currently recommended by the American Clinical Neurophysiology Society for a wide range of indications, including diagnosis of nonconvulsive status epilepticus and evaluation of unexplained disorders of consciousness. Data interpretation usually occurs by expert personnel (e.g., epileptologists, neurophysiologists), with information relayed to the primary care team. However, data cannot always be read in time-sensitive fashion, leading to potential delays in EEG interpretation and patient management. Multiple training programs have recently been described to enable non-experts to rapidly interpret EEG at the bedside. A comprehensive review of these training programs, including the tools used, outcomes obtained, and potential pitfalls, is currently lacking. Therefore, the optimum training program and implementation strategy remain unknown. METHODS: We will conduct a systematic review of descriptive studies, case series, cohort studies, and randomized controlled trials assessing training programs for EEG interpretation by non-experts. Our primary objective is to comprehensively review educational programs in this domain and report their structure, patterns of implementation, limitations, and trainee feedback. Our secondary objective will be to compare the performance of non-experts for EEG interpretation with a gold standard (e.g., interpretation by a certified electroencephalographers). Studies will be limited to those performed in acute care settings in both adult and pediatric populations (intensive care unit, emergency department, or post-anesthesia care units). Comprehensive search strategies will be developed for MEDLINE, EMBASE, WoS, CINAHL, and CENTRAL to identify studies for review. The gray literature will be scanned for further eligible studies. Two reviewers will independently screen the search results to identify studies for inclusion. A standardized data extraction form will be used to collect important data from each study. If possible, we will attempt to meta-analyze the quantitative data. If heterogeneity between studies is too high, we will present meaningful quantitative comparisons of secondary outcomes as per the synthesis without meta-analysis (SWiM) reporting guidelines. DISCUSSION: We will aim to summarize the current literature in this domain to understand the structure, patterns, and pitfalls of EEG training programs for non-experts. This review is undertaken with a view to inform future education designs, potentially enabling rapid detection of EEG abnormalities, and timely intervention by the treating physician. PROSPERO REGISTRATION: Submitted and undergoing review. Registration ID: CRD42020171208 .

New-onset super refractory status epilepticus: A case-series.

INTRODUCTION: Literature on New-Onset Refractory Status Epilepticus (NORSE) is scarce and management is guided mainly by retrospective reports, short case series or expert opinions. We aimed to add to the pool of the available data by retrospectively reviewing seven cases of NORSE cases admitted to our hospital over the last five years between January 2014 and March 2019. METHODS: Fully anonymised data from medical charts, EEG reports, imaging reports, laboratory test results, types of antiepileptic medications, intravenous anaesthetic therapy, and immune therapies received was collected, along with response to treatment, length of hospital stay and outcome at discharge. RESULTS: The mean age was 43.5 ±â€¯23.8 years (range 18-75) and three patients were females. Prodromal symptoms consisted mainly of fever (4/7), headache (4/7) and self terminating seizures (7/7), before presenting with status epilepticus. Initial imaging findings were abnormal in 3/7 and CSF analysis in 3/7. All patients underwent intermittent EEG recordings, mainly for titration or tapering of the anaesthetic agents, with the initial goal of achieving burst suppression and cessation of electrographic seizures. Our index case spent the longest time in therapeutic burst suppression (102 days) and remained on thiopentone for 214 days. The mean duration of NICU stay was 88 ±â€¯85.4 days (range 4-225 days) while the mean duration of hospital stay was 113.8 ±â€¯111.2 days (range 17-292). CONCLUSIONS: The management of patients with NORSE remains challenging, often requiring multiple intravenous anaesthetic treatments, leading to complicated and prolonged hospital and intensive care unit stays but good outcome remains possible.

A pragmatic approach to intravenous anaesthetics and electroencephalographic endpoints for the treatment of refractory and super-refractory status epilepticus in critical care.

Status epilepticus is a common neurological emergency, with overall mortality around 20%. Over half of cases are first time presentations of seizures. The pathological process by which spontaneous seizures are generated arises from an imbalance in excitatory and inhibitory neuronal networks, which if unchecked, can result in alterations in intracellular signalling pathways and electrolyte shifts, which bring about changes in the blood brain barrier, neuronal cell death and eventually cerebral atrophy. This narrative review focusses on the treatment of status epilepticus in adults. Anaesthetic agents interrupt neuronal activity by enhancing inhibitory or decreasing excitatory transmission, primarily via GABA and NMDA receptors. Intravenous anaesthetic agents are commonly used as second or third line drugs in the treatment of refractory status epilepticus, but the optimal timing and choice of anaesthetic drug has not yet been established by high quality evidence. Titration of antiepileptic and anaesthetic drugs in critically ill patients presents a particular challenge, due to alterations in drug absorbtion and metabolism as well as changes in drug distrubution, which arise from fluid shifts and altered protein binding. Furthermore, side effects associated with prolonged infusions of anaesthetic drugs can lead to multi-organ dysfunction and a need for critical care support. Electroencelography can identify patterns of burst suppression, which may be a target to guide weaning of intravenous therapy. Continuous elctroencephalography has the potential to directly impact clinical care, but despite its utility, major barriers exist which have limited its widespread use in clinical practice. A flow chart outlining the timing and dosage of anaesthetic agents used at our institution is provided.