Feasibility of Prompt Lumbar Drainage in Patients with Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Numerous studies have shown that continuous lumbar drainage (LD) reduces spontaneous subarachnoid hemorrhage (SAH)-related complications, decreasing the incidence of cerebral vasospasm, delayed cerebral ischemia , and hydrocephalus in patients treated with coiling or clipping, but performing LD before securing the aneurysm is still controversial. Our hospital has been implementing prompt LD for several years, and we present the results in this paper. METHODS: Between January 2014 and December 2020, a total of 438 patients with SAH were included in this retrospective study. The indication for prompt LD was aneurysmal SAH of modified Fisher grade III or higher without dense intraventricular hemorrhage with obstructive hydrocephalus requiring extraventricular drainage or large intracranial hemorrhage requiring immediate decompression. Prompt LD was performed for 229 patients with SAH, and the control group included 209 patients. We compared in-hospital mortality and vasospasm or hydrocephalus occurrence and procedure-related complications between the two groups. RESULTS: The in-hospital mortality rate was 7.4% for patients with prompt LD and 14.4% for patients without LD, and the difference was significant (P = 0.019). Vasospasm occurred in 10% of patients with prompt LD and 16.7% of controls (P = 0.039). Hydrocephalus requiring extraventricular drainage occurred in 10.9% of the LD group and 28.7% of the control group (P < 0.001). Rebleeding occurrence was 3.1% in the prompt LD group and 5.7% in the non-LD group (P = 0.168). Cerebrospinal fluid infection occurred in 0.4% of the prompt LD group and 1.4% of controls(P = 0.272). CONCLUSIONS: Prompt LD is a feasible option for treating patients with selective aneurysmal SAH.

Post-Intensive Care Syndrome in Non-COVID-19 ICU Survivors during the COVID-19 Pandemic in South Korea: A Multicenter Prospective Cohort Study.

A prospective observational cohort study investigated the prevalence of post-intensive care syndrome (PICS) among non-COVID-19 ICU survivors during the COVID-19 pandemic. Adults who had been admitted to the ICU for more than 24 h were enrolled, and followed-up at 3, 6, and 12 months post-discharge. PICS (mental health, cognitive, and physical domains) was measured using the Hospital Anxiety and Depression Scale, Posttraumatic Diagnosis Scale, Montreal Cognitive Assessment, and Korean Activities of Daily Living (ADL) scale. Data were analyzed from 237 participants who completed all three follow-up surveys. The prevalence of PICS was 44.7%, 38.4%, and 47.3%, at 3, 6, and 12 months of discharge, respectively. The prevalence of PICS in the mental health and cognitive domains decreased at 6 and increased at 12 months. The prevalence of PICS in the physical domain declined over time. Changes in PICS scores other than ADL differed significantly according to whether participants completed follow-up before or after December 2020, when COVID-19 rapidly spread in South Korea. In the recent group, anxiety, depression, post-traumatic stress disorder, and cognition scores were significantly worse at 12 months than at 6 months post-discharge. The COVID-19 pandemic may have adversely affected the recovery of non-COVID-19 ICU survivors.

Effectiveness and safety of EVT in patients with acute LVO and low NIHSS.

Background and purpose: There is much uncertainty in endovascular treatment (EVT) decisions in patients with acute large vessel occlusion (LVO) and mild neurological deficits. Methods: From a prospective, nationwide stroke registry, all patients with LVO and baseline NIHSS <6 presenting within 24 h from the time last known well (LKW) were included. Early neurological deterioration (END) developed before EVT was prospectively collected as an increasing total NIHSS score ≥2 or any worsening of the NIHSS consciousness or motor subscores during hospitalization not related to EVT. Significant hemorrhage was defined as PH2 hemorrhagic transformation or hemorrhage at a remote site. The modified Rankin Scale (mRS) was prospectively collected at 3 months. Results: Among 1,083 patients, 149 (14%) patients received EVT after a median of 5.9 [3.6-12.3] h after LKW. In propensity score-matched analyses, EVT was not associated with mRS 0-1 (matched OR 0.99 [0.63-1.54]) but increased the risk of a significant hemorrhage (matched OR, 4.51 [1.59-12.80]). Extraneous END occurred in 207 (19%) patients after a median of 24.5 h [IQR, 13.5-41.9 h] after LKW (incidence rate, 1.41 [95% CI, 1.23-1.62] per 100 person-hours). END unrelated to EVT showed a tendency to modify the effectiveness of EVT (P-for-interaction, 0.08), which decreased the odds of having mRS 0-1 in mild LVO patients without END (adjusted OR, 0.63 [0.40-0.99]). Conclusions: The use of EVT in patients with acute LVO and low NIHSS scores may require the assessment of individual risks of early deterioration, hemorrhagic complications and expected benefit.

The relationship between person-centred care and the intensive care unit experience of critically ill patients: A multicentre cross-sectional survey.

BACKGROUND: Person-centred care has the potential to improve the patient experience in the intensive care unit (ICU). However, the relationship between person-centred care perceived by critically ill patients and their ICU experience has yet to be determined. OBJECTIVES: The aim of this study was to investigate the relationship between person-centred care and the ICU experience of critically ill patients. METHODS: This study was a multicentre, cross-sectional survey involving 19 ICUs of four university hospitals in Busan, Korea. The survey was conducted from June 2019 to July 2020, and 787 patients who had been admitted to the ICU for more than 24 hours participated. We measured person-centred care using the Person-Centered Critical Care Nursing perceived by Patient Questionnaire. Participants' ICU experience was measured by the Korean version of the Intensive Care Experience Questionnaire that consists of four subscales. We analysed the relationship between person-centred care and each area of the ICU experience using multivariate linear regression. RESULTS: Person-centred care was associated with 'awareness of surroundings' (ß = 0.29, p < .001), 'frightening experiences' (ß = -0.31, p < .001), and 'satisfaction with care' (ß = 0.54, p < .001). However, there was no significant association between person-centred care and 'recall of experience'. CONCLUSIONS: We observed that person-centred care was positively related to most of the ICU experiences of critically ill patients except for recall of experience. Further studies on developing person-centred nursing interventions are needed.

Impact of Neurointensivist Co-Management in a Semiclosed Neurocritical-Care Unit.

BACKGROUND AND PURPOSE: The importance of the specialized management of neurocritical patients is being increasingly recognized. We evaluated the impact of neurointensivist comanagement on the clinical outcomes (particularly the mortality rate) of neurocritical patients admitted to a semiclosed neurocritical-care unit (NCU). METHODS: We retrospectively included neurocritical patients admitted to the NCU between March 2015 and February 2018. We analyzed the clinical data and compared the outcomes between patients admitted before and after the initiation of neurointensivist co-management in March 2016. RESULTS: There were 1,785 patients admitted to the NCU during the study period. Patients younger than 18 years (n=28) or discharged within 48 hours (n=200) were excluded. The 1,557 remaining patients comprised 590 and 967 who were admitted to the NCU before and after the initiation of co-management, respectively. Patients admitted under neurointensivist co-management were older and had higher Acute Physiologic Assessment and Chronic Health Evaluation II scores. The 30-day mortality rate was significantly lower after neurointensivist co-management (p=0.042). A multivariate logistic regression analysis demonstrated that neurointensivist co-management significantly reduced mortality rates in the NCU and in the hospital overall [odds ratio=0.590 (p=0.002) and 0.585 (p=0.001), respectively]. CONCLUSIONS: Despite the higher severity of the condition during neurointensivist co-management, co-management significantly improved clinical outcomes (including the mortality rate) in neurocritical patients.

A Dedicated Neurological Intensive Care Unit Offers Improved Outcomes for Patients With Brain and Spine Injuries.

BACKGROUND: Admission to an intensive care unit (ICU) specialized for brain and spine injury patients is associated with improved outcome. We investigated the effects of the first dedicated, combined neurological and neurosurgical ICU (NeuroICU) in Korea on patient outcomes. METHODS: The first dedicated NeuroICU in Korea was established in March 2013. We retrospectively analyzed the clinical data and compared the outcomes between patients admitted to the ICU before and after NeuroICU establishment. The predicted mortality of NeuroICU patients was calculated using their Acute Physiology and Chronic Health Evaluation II scores. Patients' functional outcomes were evaluated using their modified Rankin scale (mRS) scores at 6 months after ICU admission, which were obtained from medical records or telephone interviews. RESULTS: We included 2487 patients, 1572 and 915 of whom were admitted prior to and after NeuroICU establishment, respectively. The demographic characteristics, Glasgow Coma Scale scores, and disease proportions did not differ significantly between the groups. The length of ICU stay and the number of days on ventilation were significantly lower in NeuroICU patients than they were in general ICU patients ( P = .024, P = .001). Intensive care unit mortality was significantly lower in NeuroICU patients (7.3% vs 4.7%, P = .012). The predicted mortality was obtained from 473 NeuroICU patients. The mortality ratio (observed mortality/predicted mortality) was 0.34 (8.9%/26.1%), and 228 (48.1%) patients showed good functional recovery (mRS, 0-2). CONCLUSION: Our findings suggest that admission to a dedicated NeuroICU significantly improves the neurological outcomes of patients with brain and spine injuries, including their postoperative care, in Korea.

Effect of statin on progression of symptomatic basilar artery stenosis and subsequent ischemic stroke.

BACKGROUND AND OBJECTIVE: Symptomatic basilar artery stenosis (BAS) is associated with high risk of ischemic stroke recurrence. We aimed to investigate whether statin therapy might prevent the progression of symptomatic BAS and stroke recurrence. METHODS: We retrospectively analyzed the data of patients with acute ischemia with symptomatic BAS, which was assessed using magnetic resonance angiogram (MRA) imaging on admission day, and 1 year later (or the day of the clinical event). The clinical endpoints were recurrent ischemic stroke and its composites, transient ischemic attack, coronary disease, and vascular death. RESULTS: Of the 153 patients with symptomatic BAS, 114 (74.5%) were treated with a statin after experiencing a stroke. Statin therapy significantly prevented the progression of symptomatic BAS (7.0% vs 28.2%) and induced regression (22.8% vs 15.4%) compared to non-statin users (p = 0.002). There were 31 ischemic stroke incidences and 38 composite vascular events. Statin users showed significantly lower stroke recurrence (14.9% vs 35.9%, p = 0.05) and composite vascular events (17.5% vs 46.2%; odds ratio [OR], 0.29; 95% confidence interval [CI], 0.13-0.64) than those not using statins did. Recurrent stroke in the basilar territory and composite vascular events were more common in patients with progression of BAS than they were in other patients (OR, 5.16; 95% CI, 1.63-16.25 vs OR, 4.2; 95% CI, 1.56-11.34). CONCLUSION: Our study suggests that statin therapy may prevent the progression of symptomatic BAS and decrease the risk of subsequent ischemic stroke. Large randomized trials are needed to confirm this result.

Extended Use of Hypothermia in Elderly Patients with Malignant Cerebral Edema as an Alternative to Hemicraniectomy.

BACKGROUND AND PURPOSE: The use of decompressive hemicraniectomy (DHC) for the treatment of malignant cerebral edema can decrease mortality rates. However, this benefit is not sufficient to justify its use in elderly patients. We investigated the effects of therapeutic hypothermia (TH) on safety, feasibility, and functional outcomes in elderly patients with malignant middle cerebral artery (MCA) infarcts. METHODS: Elderly patients 60 years of age and older with infarcts affecting more than two-thirds of the MCA territory were included. Patients who could not receive DHC were treated with TH. Hypothermia was started within 72 hours of symptom onset and was maintained for a minimum of 72 hours with a target temperature of 33°C. Modified Rankin Scale (mRS) scores at 3 months following treatment and complications of TH were used as functional outcomes. RESULTS: Eleven patients with a median age of 76 years and a median National Institutes of Health Stroke Scale score of 18 were treated with TH. The median time from symptom onset to initiation of TH was 30.3±23.0 hours and TH was maintained for a median of 76.7±57.1 hours. Shivering (100%) and electrolyte imbalance (82%) were frequent complications. Two patients died (18%). The mean mRS score 3 months following treatment was 4.9±0.8. CONCLUSIONS: Our results suggest that extended use of hypothermia is safe and feasible for elderly patients with large hemispheric infarctions. Hypothermia may be considered as a therapeutic alternative to DHC in elderly individuals. Further studies are required to validate our findings.

Dysphagia May Be an Independent Marker of Poor Outcome in Acute Lateral Medullary Infarction.

BACKGROUND AND PURPOSE: The functional recovery after the lateral medullary infarction (LMI) is usually good. Little is known about the prognostic factors associated with poor outcome following acute LMI. The aim of this study was to identify the factors associated with poor long-term outcome after acute LMI, based on experiences at a single center over 11 years. METHODS: A consecutive series of 157 patients with acute LMI who were admitted within 7 days after symptom onset was evaluated retrospectively. Clinical symptoms were assessed within 1 day after admission, and outcomes were evaluated over a 1-year period after the initial event. The lesions were classified into three vertical types (rostral, middle, and caudal), and the patients were divided into two groups according to the outcome at 1 year: favorable [modified Rankin Scale (mRS) score ≤1] and unfavorable (mRS score ≥2). RESULTS: Of the 157 patients, 93 (59.2%) had a favorable outcome. Older age, hypertension, dysphagia, requirement for intensive care, and pneumonia were significantly more prevalent in the unfavorable outcome group. The frequencies of intensive care (13%) and mortality (16.7%) were significantly higher in the rostral lesion (p=0.002 and p=0.002). Conditional logistic regression analysis revealed that older age and initial dysphagia were independently related to an unfavorable outcome at 1 year [odds ratio (OR)=1.04, 95% confidence interval (95% CI)=1.001-1.087, p=0.049; OR=2.46, 95% CI=1.04-5.84, p=0.041]. CONCLUSIONS: These results suggest that older age and initial dysphagia in the acute phase are independent risk factors for poor long-term prognosis after acute LMI.

Dose-specific effect of simvastatin on hypoxia-induced HIF-1α and BACE expression in Alzheimer's disease cybrid cells.

BACKGROUND: Alzheimer's disease (AD) is associated with vascular risk factors; brain ischemia facilitates the pathogenesis of AD. Recent studies have suggested that the reduction of AD risk with statin was achieved by decreased amyloidogenic amyloid precursor protein. METHODS: We used mitochondrial transgenic neuronal cell (cybrid) models to investigate changes in the levels of intracellular hypoxia inducible factor 1α (HIF-1α) and ß-site amyloid precursor protein cleaving enzyme (BACE) in the presence of simvastatin. Sporadic AD (SAD) and age-matched control (CTL) cybrids were exposed to 2% O2 and incubated with 1 µM or 10 µM simvastatin. RESULTS: There was no significant difference between cell survival by 1 or 10 µM simvastatin in both SAD and CTL cybrids. In the presence of 1 µM simvastatin, intracellular levels of HIF-1α and BACE decreased by 40-70% in SAD, but not CTL cybrids. However, 10 µM simvastatin increased HIF-1α and BACE expression in both cybrid models. CONCLUSION: Our results suggest demonstrate differential dose-dependent effects of simvastatin on HIF-1α and BACE in cultured Alzheimer's disease cybrid cells.

Recanalization Rate and Clinical Outcome in Acute Carotid-T Occlusion.

BACKGROUND: Acute carotid-T occlusion results in both low recanalization rates and poor outcomes. We investigated clinical outcomes and recanalization in a rare case of thrombolytic therapy. METHODS: A consecutive series of patients with acute carotid-T occlusion who were treated with either bridging intravenous (IV) plus intra-arterial (IA) thrombolysis or IA alone were analyzed. Complete recanalization was defined as a thrombolysis in cerebral infarction (TICI) grade of 3. A favorable outcome was defined as a modified Rankin Scale (mRS) score of ≤2. RESULTS: Of the 40 patients, 6 (15%) had favorable outcomes, and 34 (85%) had poor outcomes. Favorable outcomes were significantly associated with a lower National Institutes of Health Stroke Scale (NIHSS) score after revascularization treatment and higher rates of complete recanalization (p < 0.01, p < 0.024, respectively). Complete recanalization was achieved in all patients with favorable clinical outcomes and 5 (83%) patients had received combined IV/IA thrombolysis (p = 0.381). CONCLUSIONS: The results suggest that complete recanalization for acute carotid-T occlusion improves clinical outcomes. In that regard, bridging IV/IA thrombolysis may be more efficacious than IA alone.