Clinical efficacy of plasma exchange in patients with autoimmune encephalitis.

OBJECTIVE: To determine the clinical and antibody response after therapeutic plasma exchange (TPE) in patients with severe refractory antibody-associated autoimmune encephalitis (AE). METHODS: This single-center prospective cohort included all patients consecutively admitted to our hospital because of severe refractory AE over the period from July 2014 to June 2019. All patients received immunotherapy (steroids, intravenous immunoglobulin (IVIG), and/or TPE). The primary outcome was evaluated at 1- and 2-month postenrollment, and the long-term outcome was followed up at 6 and 12 months. AE antibody titers in the cerebrospinal fluid and plasma were evaluated before and after TPE/IVIG. RESULTS: This study enrolled 57 patients with severe refractory AE, including anti-NMDA receptor encephalitis (n = 51), anti-GABAb receptor encephalitis (n = 3), anti-LGI 1 encephalitis (n = 2), and anti-AMPA receptor encephalitis (n = 1). Of all 57 patients, 33 patients received TPE for a total of 193 procedures, and 24 patients with contraindications or refusal of TPE were in the non-TPE group. Compared with the non-TPE group, the TPE group exhibited greater clinical improvement: 21 (37%) versus 8 (14%) after 1 month (P = 0.03) and 31 (54%) versus 16 (28%) after 2 months (P = 0.01), respectively. Complications and adverse events associated with TPE occurred in 91 procedures (47%) without serious adverse events associated with the use of TPE. INTERPRETATION: TPE might be an effective rescue therapy associated with rapid functional improvement in patients with severe steroid/IVIG refractory antibody-associated AE from this nonrandomized control trial.

An Investigation and Suggestions for the Improvement of Brain Death Determination in China.

BACKGROUND: Brain death is the irreversible cessation of the function of the brain including the brainstem. In 2013, the Brain Injury Evaluation Quality Control Centre (BQCC) of the National Health and Family Planning Commission issued criteria and practical guidelines for the determination of brain death. This study aimed to evaluate whether the institutions have adopted these guidelines and to make suggestions for the improvement of the current criteria and practical guidelines for brain death determination in China. METHODS: Consecutive brain death cases from 44 hospitals were evaluated for summary statistics for the following data: the performance of BQCC criteria and practical guidelines, clinical examination, apnea testing, ancillary testing, and the number of examinations as well as the waiting periods between examinations and details of who determined brain death. Data analysis was conducted from January 2013 to December 2017. RESULTS: A total of 550 cases were obtained. All patients were determined to have deep coma and met the prerequisites for clinical testing. The performance rates of four brainstem reflex examinations (except cough reflex) ranged from 97.5% to 98.0%, and the completion rate as well as the coincidence rate were both 100.0%. The 238 cases (50.7%) completed apnea testing, and 231 cases (42.0%) had to stop apnea testing during the examination because of instability. The performance rates of the three ancillary tests, including electroencephalogram, short-latency somatosensory evoked potential, and transcranial Doppler, were 89.5%, 67.5%, and 79.5%, respectively; furthermore, the coincidence rates were 98.6%, 96.5%, and 99.5%, respectively. The combination of two ancillary tests was more accurate than one single ancillary test. A total of 401 (72.9%) cases successfully underwent two separate examinations to determine brain death with at least a 12-h waiting period. All brain death cases were determined by at least two qualified physicians. CONCLUSION: This study might provide suggestions for brain death determination in China.

Thioredoxin is a novel diagnostic and prognostic marker in patients with ischemic stroke.

Serum thioredoxin (TRX), a redox-regulating protein with antioxidant activity, was recognized as an oxidative-stress marker. The purpose of this study was to investigate the potential diagnostic and prognostic role of TRX in Chinese patients with acute ischemic stroke (AIS). From January 1, 2012, to December 31, 2013, all patients with first-ever acute ischemic stroke were recruited to participate in the study. Serum levels of TRX were assayed with solid-phase sandwich ELISA, and severity of stroke was evaluated with the National Institutes of Health Stroke Scale (NIHSS) score on admission. Short-term functional outcome was measured by a modified Rankin scale (mRS) 3 months after admission. Multivariate analyses were performed using logistic regression models. We found the serum TRX reflected the disease severity of AIS. There was a significant positive association between serum TRX levels and NIHSS scores (r= 0.476, P<0.0001). Based on the ROC curve, the optimal cutoff value of serum TRX levels as an indicator for auxiliary diagnosis of AIS was projected to be 11.0 ng/ml, which yielded a sensitivity of 80.3% and a specificity of 73.7%, with the area under the curve at 0.807 (95% CI, 0.766-0.847). Elevated TRX (≥ 20.0 ng/ml) was an independent prognostic marker of short-term functional outcome [odds ratio (OR) 9.482 (95% CI, 3.11-8.15) P<0.0001; adjusted for NIHSS, other predictors and vascular risk factors] in patients with AIS. TRX improved the area under the receiver operating characteristic curve of the NHISS score for functional outcome from 0.722 (95% CI, 0.662-0.782) to 0.905 (95% CI, 0.828-0.962; P<0.0001). Our study demonstrated that elevated serum TRX level at admission was a novel diagnostic and prognostic marker in patients with acute ischemic stroke.

An overview of neurocritical care in China: a nationwide survey.

BACKGROUND: Little quantitative evidence was available regarding the development of NICUs in China. The purpose of this survey was to evaluate the current situation of neurointensive care units (NICUs) across China. METHODS: The directors of NICUs from 100 tertiary care hospitals across China were contacted and asked to complete a closed response questionnaire regarding their NICUs. Basic information, equipment, and technology information available in the units, as well as staffing information were investigated. RESULTS: Seventy-six questionnaires were returned (a 68% response rate). Of 76 NICUs, 43 units constituted the majority. The number of each NICU bed varied from 4 to 45, occupying 2%-30% of the total department beds. Over 70% of NICUs were equipped with many emergency treatment equipments as well as physiological and biochemical monitoring equipments, while 34%-70% of NICUs still lacked some kinds of equipments such as defibrillators. Some specialist equipments were still partially lacking in 62%-95% of NICUs. A vast majority of the NICUs were equipped with neurocritical care directors, full-time attending physicians, and head nurses, but full-time NICU residents and neurocritical care nurses were still lacking in nearly half (53%) and one-third (33%-37%) of NICUs, respectively. In 76 NICUs, full-time neurointensivists and nurses added up to 359 and 852, respectively. In addition, 78%-97% of all the surveyed NICUs were severely short of non-neurological professional staffs. CONCLUSION: In China, neurocritical care has developed rapidly, but there is still a shortage of well-equipped and well-staffed NICUs across the nation currently.

Early prediction of poor outcome in severe hemispheric stroke by EEG patterns and gradings.

OBJECTIVES: To find out the EEG abnormal patterns in massive cerebral hemispheric infarction (MCHI) and their correlation with poor outcome, and to construct an EEG grading for predicting the outcome of MCHI patients. METHODS: Between 2000 and 2010, 162 patients with MCHI who met the selection criterions were selected for this study. All the patients underwent EEG examinations within 3 days after stroke onset and repeated on day 2 and 3. We classified the EEG recordings into 9 patterns and anglicized the correlation between EEG patterns and outcome. Then according to the results of the correlation between EEG patterns and outcome we constructed an EEG grading for predicting the outcome of MCHI patients. RESULTS: We revealed that patterns of dominant alpha without reactivity, RAWOD, burst-suppression, α/θ-coma, epileptiform activity (without burst-suppression), and generalized suppression were correlated to poor outcome. We further modified the Young grading according to the correlation between EEG patterns and outcome. We found that the modified grading was superior to existing EEG gradings in predicting the outcome of MCHI patients, and it could predict the outcome of MCHI more accurately. CONCLUSIONS: MCHI is common in N-ICU (Neurology Intensive Care Unit). The EEG analysis would detect the degree of brain lesion during the ischemia within the acute stage after stroke onset. The EEG evaluation might assist the neurophysicians to predict outcome of patients and make decisions on the treatments.

Evaluation of neuro-intensive care unit performance in China: predicting outcomes of Simplified Acute Physiology Score II or Glasgow Coma Scale.

BACKGROUND: Severity scoring systems are useful tools for measuring the severity of the disease and its outcome. This pilot study was to verify and compare the prognostic performance of the Simplified Acute Physiology Score II (SAPS II) and Glasgow Coma Scale (GCS) in neuro-intensive care unit (N-ICU) patients. METHODS: A total of 1684 patients consecutively admitted to the N-ICU at Xuanwu Hospital between January 1, 2005 and December 31, 2011 were enrolled in this study. The data-base included admission data, at 24-, 48-, and 72-hour SAPS II and GCS. Repeated measure data analysis of variance, Logistic regression analysis, the Hosmer-Lemeshow goodness-of-fit statistic, and the area under the receiver operating characteristic were used to evaluate the performance. RESULTS: There was a significant difference between the SAPS II or GCS score at four time points (F = 16.110, P = 0.000 or F = 8.108, P = 0.000). The SAPS II scores or GCS score at four time points interacted with the outcomes with significant difference (F = 116.771, P = 0.000 or F = 65.316, P = 0.000). Calibration of the SAPS II or GCS score at each time point on all patients was good. The percentage of a risk estimate prediction corresponding to observed mortality was also good. The 72-hour score have the greatest consistency. Discriminations of the SAPS II or GCS score at each time were all satisfactory. The 72-hour score had the greatest discriminative power. The cut-off value was 33 (sensitivity of 85.2% and specificity of 74.3%) and 6 (sensitivity of 70.6% and specificity of 65.0%). The SAPS II at each time point on all patients showed better calibration, consistency and discrimination than GCS. The binary Logistic regression analysis identified physiological variables, GCS, age, and disease category as significant independent risk factors of death. After the two variables including underlying disease and type of admission were excluded, we built the simplified SAPS II model. A correlation was suggested between the simplified SAPS II score at each time point and outcome, regardless of the diagnosis. CONCLUSIONS: The GCS scoring system tends to be a little weaker in the predictive power than the SAPS II scoring system in this Chinese cohort of N-ICU patients. The advantage of SAPS II scoring system still exists that it dose not need to take into account the diagnosis or diseases categories, even in the special N-ICU. The simplified SAPS II scoring system is considered a new idea for the estimation of effectiveness.

Predicting comatose patients with acute stroke outcome using middle-latency somatosensory evoked potentials.

OBJECTIVE: To evaluate the prognostic value of middle-latency somatosensory evoked potential (MLSEP) in comatose patients with acute severe supratentorial stroke, considering both unfavourable outcome and death. METHODS: Eighty-eight patients with acute severe supratentorial stroke underwent MLSEP, short-latency somatosensory evoked potential (SLSEP), Glasgow Coma Scale (GCS) and cerebral computed tomography (CCT) within 1 week from onset. MLSEP and SLSEP were recorded in 25 normal controls. All patients were evaluated with two criteria of outcome as unfavourable outcome (modified Rankin Scale 4-6) and death 6 months after onset. N60 of MLSEP predictive value was compared with N20 of SLSEP, GCS and CCT. RESULTS: Sixty-seven patients (76.1%) suffered from cerebral infarction; and 21 patients (23.9%) suffered from intracerebral haemorrhage. Seventy-one patients (80.7%) had unfavourable outcomes and 39 patients (44.3%) died. The peak latencies of MLSEP were prolonged and some waves of MLSEP were absent in stroke patients, and the proportion of absent waves in lesion-ipsilateral MLSEP was higher than in contralateral MLSEP. By using the prognostic authenticity analysis of predictors, the lesion-ipsilateral absence of N60 showed the highest sensitivity for unfavourable outcome (97.2%, confidence interval (CI): 89.3-99.5%) and death (100%, CI: 88.8-100%), which was superior to GCS, CCT and N20. Bilateral absence of N60 showed a high specificity of 100% for unfavourable outcome, which was as good as bilateral absence of N20. However, it showed a specificity of 89.8% (CI: 77.0-96.2%) for death, not as good as bilateral absence of N20 (98%, CI: 87.8-99.9%). The false positive rate of lesion-ipsilateral absence of N60 for unfavourable outcome and death was 12.7% (CI: 6.6-22.5%) and 50.6% (CI: 39.2-62.0%), respectively, and that of bilateral absence of N60 was 0 (CI: 0-12.3%) and 14.3% (CI: 5.4-31.0%), respectively. CONCLUSIONS: We confirm the high predictive value of MLSEP in severe stroke. MLSEP showed higher sensitivity than SLSEP for predicting unfavourable outcome and death. Combined MLSEP with SLSEP results produced even greater predictive value. SIGNIFICANCE: The combination of MLSEP and SLSEP would increase the sensitivity and maintain the high specificity not only for predicting outcome in coma after cardiopulmonary resuscitation but also after severe stroke.