Intraoperative cerebral oxygen saturation and neurological outcomes following surgical management of necrotizing enterocolitis: Predictive factors of neurological complications following neonatal necrotizing enterocolitis: Predictive factors of neurological complications following neonatal necrotizing enterocolitis.

BACKGROUND: The goal of the present study was to investigate intraoperative factors associated with major neurological complications at 1 year following surgery for necrotizing enterocolitis. MATERIAL AND METHODS: The study consisted of a retrospective review of medical charts of patients operated for over one calendar year in one institution. Data collected included demographic data, cardiac resuscitation at birth, Bell classification, antibiotics usage, time of day of surgery, surgical technique, surgical duration, type of ventilation, intraoperative vasoactive agents, and albumin use, nadir cerebral saturation, the decrease in cerebral saturation from baseline, the time period when cerebral saturation was at least 20% below baseline, and the mean arterial pressure at nadir cerebral saturation. Reported follow-up complications were assessed during formal neonatologist consultation and additional imaging exploration as needed. Analyses included descriptive statistics, and univariable and multivariable statistics. RESULTS: The study included 32 patients with no prior clinical neurological complications, of which 25 had normal cerebral imaging. Severe neurological complications occurred in nine patients at 1 year: Intraventricular hemorrhage (N = 2) and Periventricular leukomalacia (N = 7). However, preoperative cerebral imaging was lacking in seven patients. Consequently, the observed neurological complications at 1 year might be present before the surgery. Multivariable analysis found the decrease in cerebral saturation ≥36% from baseline as the only factor associated with the occurrence of those complications. CONCLUSION: Intraoperative decrease of cerebral oxygen saturation below ≥36% from baseline is associated with severe neurological complications in neonates undergoing surgery for necrotizing enterocolitis.

Case Studies in Neuroscience: Transcranial Doppler assessment of increased cerebral blood flow during iterative seizures.

This case study aimed at monitoring ictal vasodilation in a clinical setting to confirm the experimental data on enhanced cerebral perfusion during epileptic seizures. Clinical observation of a patient presenting relapsing seizures in the intensive care unit. Transcranial Doppler (TCD) was used to monitor both blood velocities and the arterial caliber in the B-flow mode as a proxy of blood flow of the middle cerebral artery (MCA). A 35-yr-old woman experienced partial epileptic seizures lasting for 1 min that recurred every 5 min. Seizures were monitored with continuous EEG and TCD. During the seizure, the MCA caliber increased whereas velocities remained stable, which doubled the MCA blood flow. Immediately after the seizure, the artery caliber returned to its initial value, and the velocities increased by one-third of the initial value. After intensification of antiepileptic treatment, clinical seizures ceased, and TCD findings returned to normal MCA caliber and velocities. Autoimmune encephalitis was identified by brain biopsy and the patient recovered with corticosteroids treatment. This is the first description of ictal vasodilatation assessed by TCD. Our current understanding holds that cerebral blood flow increases during a seizure, but our report demonstrates that arterial dilation preceded the acceleration of velocities. This case study in a clinical setting confirms the impact of seizures on cerebral blood flow. NEW & NOTEWORTHY The case study is a clinical demonstration of ictal vasodilation. By assessing arterial caliber and blood velocities with transcranial Doppler, we dissected the impact of seizures on blood flow of the middle cerebral artery in the following sequence: 1) vasodilation occurred, concomitant to the epileptic activity, whereas the blood velocities remained stable and 2) immediately after the seizure, the velocities increased and the artery caliber returned to its initial value. As per author, there was no protocol, but one patient gave consent to use data from her medical file.

Ischemic and hemorrhagic brain injury during venoarterial-extracorporeal membrane oxygenation.

BACKGROUND: Structural neurological complications (ischemic stroke and intracranial bleeding) and their risk factors in patients receiving venoarterial-extracorporeal membrane oxygenation (VA-ECMO) are poorly described. Our objective was to describe frequencies, outcomes and risk factors for neurological complications (ischemic stroke and intracranial bleeding) in patients receiving VA-ECMO. METHODS: Retrospective observational study conducted, from 2006 to 2014, in a tertiary referral center on patients who developed a neurological complication(s) on VA-ECMO. RESULTS: Among 878 VA-ECMO-treated patients, 65 (7.4%) developed an ECMO-related brain injury: 42 (5.3%) ischemic strokes and 20 (2.8%) intracranial bleeding, occurring after a median [25th;75th percentile] of 11 [6;18] and 5 [2;9] days of support, respectively. Intracranial bleeding but not ischemic stroke was associated with higher mortality. Multivariable analysis retained only platelet level > 350 giga/L as being associated with ischemic stroke. Female sex, central VA-ECMO and platelets < 100 giga/L at ECMO start were independently associated with intracranial bleeding with respective odds ratios [95% CI] of 2.9 [1.1-7.5], 3.8 [1.1-10.2] and 3.7 [1.4-9.7]. In a nested case-control study, rapid CO2-level change from before-to-after ECMO start also seemed to be associated with intracranial bleeding. CONCLUSIONS: Neurological events are frequent in VA-ECMO-treated patients. Ischemic stroke is the most frequent, occurs after 1 week on ECMO support, has no specific risk factor and is not associated with higher mortality. Intracranial bleeding occurs earlier and is associated with female sex, central VA-ECMO, low platelet count and rapid CO2 change at ECMO start, and high mortality. LEVEL OF EVIDENCE: This study provides Class IV evidence that central VA-ECMO, low platelet count and rapid CO2 change at ECMO start are associated with intracranial bleeding and high mortality.