Correlation Between Cerebral Autoregulation and Carbon Dioxide Reactivity in Patients with Traumatic Brain Injury.

OBJECTIVE: Cerebral blood flow autoregulation is commonly impaired in patients with traumatic brain injury (TBI). This study was to investigate correlations between cerebral autoregulation and CO2 reactivity in patients with TBI during transient mild hypocapnia. METHODS: Patients with TBI who were on mechanical ventilation were hyperventilated for approximately 60 min. Indices of autoregulation, based on a model of the relationship between arterial blood pressure and blood flow velocity (FV) (ARIabp) and, separately, between cerebral perfusion pressure and FV (ARIcpp), were calculated. Mean flow index (Mx) was also calculated. RESULTS: We investigated 31 consecutive patients. At baseline, median PaCO2 was 5.09 kPa (range 4.30-5.67 kPa); during hyperventilation, median PaCO2 was 4.38 kPa (range 3.72-4.96 kPa). ARI was associated with Mx (ARIabp vs. Mx: r = -0.39, p = 0.04; ARIcpp vs Mx: r = -0.67, p < 0.001). CO2 reactivity showed significant correlation with ARIcpp (r = 0.41, p = 0.04) and Mx (r = -0.37, p = 0.04). ARI after hyperventilation was significantly higher than ARI at baseline (ARIcpp: p = 0.02; ARIabp: p < 0.001). CONCLUSIONS: Cerebral autoregulation seemed to be well linked to CO2 reactivity during transient hyperventilation. ARIcpp had a stronger correlation with CO2 reactivity than ARIabp. ARI indicated improvement of autoregulation during hyperventilation. Cerebral autoregulation indices (ARI, Mx) were associated with each other.

Mortality of cerebral venous-sinus thrombosis in a large national sample.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the mortality rates associated with cerebral venous-sinus thrombosis in a large national sample. METHODS: A cohort of patients with cerebral venous-sinus thrombosis was identified from the National Inpatient Sample database for the years 2000 to 2007. According to the International Classification of Diseases, 9th Revision, Clinical Modification codes, cerebral venous-sinus thrombosis is categorized into pyogenic and nonpyogenic groups. Multivariate logistic regression analysis was used to assess covariates associated with hospital mortality. RESULTS: Among 3488 patients, the overall mortality rate was 4.39%, which was nonsignificantly higher among the pyogenic group (4.55% versus 3.52%; OR, 0.76; 95% CI, 0.47-1.23). In the pyogenic cerebral venous-sinus thrombosis group, hematologic disorders were the most frequent predisposing condition (16.2%); whereas systemic malignancy followed by hematologic disorders were most common in the nonpyogenic group (14.08% and 10.04%, respectively). Predictors of mortality included age, intracerebral hemorrhage as well as the predisposing conditions of hematologic disorders, systemic malignancy, and central nervous system infection. CONCLUSIONS: Compared with arterial stroke, CVST harbors a relatively low mortality rate. Death is determined by age, the presence of intracerebral hemorrhage, and certain predisposing conditions.

Is thrombolysis safe in the elderly?: analysis of a national database.

BACKGROUND AND PURPOSE: Thrombolysis for acute ischemic stroke in the elderly population is seldom administered. METHODS: In this study, we evaluated the risks of thrombolysis, including the mortality and intracerebral hemorrhage (ICH) rates in this population. A cohort of patients was identified from the National Inpatient Sample database for the years 2000-2006. Age was categorized in 2 groups, including those between 18 and 80 years and those >80 years. Multivariate logistic regression analysis was used to assess covariates associated with hospital mortality and ICH. A total of 524 997 patients were admitted for acute ischemic stroke; 143 093 (27.2%) were >80 years. A total of 7950 patients were treated with thrombolysis, of which 1659 (20.9%) were >80 years. Elderly patients received less frequent thrombolysis compared with the younger population (1.05% versus 1.72%). RESULTS: In the whole cohort, the mortality rate was higher in the older population (12.80% versus 8.99%). For those treated with thrombolysis, the mortality rate and risk of ICH were higher among those >80 years (16.9% versus 11.5%; odds ratio: 1.56 [95% CI: 1.35 to 1.82] and 5.73% versus 4.40%; odds ratio: 1.31 [95% CI: 1.03 to 1.67], respectively). Multivariate logistic regression analysis showed that the presence of ICH (odds ratio: 2.24 [95% CI: 1.89 to 2.65]) was associated with higher mortality rates but not the use of thrombolysis (odds ratio: 1.14 [95% CI: 0.98 to 1.33]). CONCLUSIONS: Despite the higher mortality rate in the older population, the use of thrombolysis does not predict death; however, the use of thrombolysis was associated with high risk of ICH.

Hospital mortality and complications of electively clipped or coiled unruptured intracranial aneurysm.

BACKGROUND AND PURPOSE: To determine the hospital mortality rates associated with elective surgical clipping and endovascular coiling of unruptured intracranial aneurysms. METHODS: We identified a cohort of patients electively admitted to US hospitals with the diagnosis of unruptured intracranial aneurysm from the National Inpatient Sample database for the years 2000 through 2006. Patient demographics, hospital-associated complications, and in-hospital mortality were compared among the treatment groups. A multivariate logistic regression analysis was used to identify independent variables associated with hospital mortality. Cochrane-Armitage test was used to assess the trend of hospital use of these procedures. RESULTS: After data cleansing, 3738 (34.3%) patients had aneurysm clipping and 3498 (32.1%) had endovascular coiling. The basic demographics including age, race, and comorbidity indices were similar between the groups. The length of hospital stay was longer in the clipped population (median 4 versus 1 day; P<0.0001), incurring a higher hospital charge in the coiled population (median $42 070 versus $38 166; P<0.0001). Hospital mortality was higher in the clipped population: 60 (1.6%) versus 20 (0.57%; adjusted odds ratio 3.63; 95% CI, 1.57, 8.42). Perioperative intracerebral hemorrhage and acute ischemic stroke were higher in the clipped population. The rate of hospital use of the endovascular coiling has increased over the years included in this study (<0.0001). CONCLUSIONS: Elective coiling of unruptured intracranial aneurysms is associated with fewer deaths and perioperative complications compared with elective clipping. The trend of hospital use of the coiling procedures has increased during recent years.

Trans-Sulcal Endoport-Assisted Evacuation of Supratentorial Intracerebral Hemorrhage: Initial Single-Institution Experience Compared to Matched Medically Managed Patients and Effect on 30-Day Mortality.

BACKGROUND: The surgical management of supratentorial intracerebral hemorrhages (ICH) remains controversial due to large trials failing to show clear benefits. Several minimally invasive techniques have emerged as an alternative to a conventional craniotomy with promising results. OBJECTIVE: To report our experience with endoport-assisted surgery in the evacuation of supratentorial ICH and its effects on outcome compared to matched medical controls. METHODS: Retrospective data were gathered of patients who underwent endoport-assisted evacuation between January 2014 and October 2016 by a single surgeon. Patients who were managed medically during the same period were matched to the surgical cohort. Previously published cohorts investigating the same technique were analyzed against the present cohort. RESULTS: Sixteen patients were identified and matched to 16 patients treated medically. Location, hemorrhage volume, and initial Glasgow Coma Scale (GCS) score did not differ significantly between the 2 cohorts. The mean volume reduction in the surgical cohort was 92.05% ± 7.05%. The improvement in GCS in the surgical cohort was statistically significant (7-13, P = .006). Compared to the medical cohort, endoport-assisted surgery resulted in a statistically significant difference in in-hospital mortality (6.25% vs 75.0%, P < .001) and 30-d mortality (6.25% vs 81.25%, P < .001). Compared to previously published cohorts, the present cohort had lower median preoperative GCS (7 vs 10, P = .02), but postoperative GCS did not differ significantly (13 vs 14, P = .28). CONCLUSION: Endoport-assisted surgery is associated with high clot evacuation and decreases 30-d mortality compared to a similar medical group.