Prediction of neurologic outcome after out-of-hospital cardiac arrest: An interpretable approach with machine learning.

Out-of-hospital cardiac arrest (OHCA) is a critical condition with low survival rates. In patients with a return of spontaneous circulation, brain injury is a leading cause of death. In this study, we propose an interpretable machine learning approach for predicting neurologic outcome after OHCA, using information available at the time of hospital admission. METHODS: The study population were 55 615 OHCA cases registered in the Swedish Cardiopulmonary Resuscitation Registry between 2010 and 2020. The dataset was split to training and validation sets (for model development) and test set (for evaluation of the final model). We used an XGBoost algorithm with stratified, repeated 10-fold cross-validation along with Optuna framework for hyperparameters tuning. The final model was trained on 10 features selected based on the importance scores and evaluated on the test set in terms of discrimination, calibration and bias-variance tradeoff. We used SHapley Additive exPlanations to address the 'black-box' model and align with eXplainable artificial intelligence. RESULTS: The final model achieved: area under the receiver operating characteristic value 0.964 (95% confidence interval (CI) [0.960-0.968]), sensitivity 0.606 (95% CI [0.573-0.634]), specificity 0.975 (95% CI [0.972-0.978]), positive predictive value (PPV) 0.664 (95% CI [0.625-0.696]), negative predictive value (NPV) 0.969 (95% CI [0.966-0.972]), macro F1 0.803 (95% CI [0.788-0.816]), and showed a very good calibration. SHAP features with the highest impact on the model's output were:'ROSC on arrival to hospital', 'Initial rhythm asystole' and 'Conscious on arrival to hospital'. CONCLUSIONS: The XGBoost machine learning model with 10 features available at the time of hospital admission showed good performance for predicting neurologic outcome after OHCA, with no apparent signs of overfitting.

Neuron-Specific Enolase as a Predictor of Neurologic Outcomes in Extracorporeal Cardiopulmonary Resuscitation Patients.

Background: Neuron-specific enolase (NSE) has traditionally been used as a biomarker to predict neurologic outcomes after cardiac arrest. This study aimed to evaluate the utility of NSE in predicting neurologic outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). Methods: This observational cohort study included 47 consecutive adult ECPR patients (median age, 59.0 years; 74.5% males) treated between January 2018 and December 2021 at a tertiary extracorporeal life support center. The primary outcome was a poor neurologic outcome, defined as a Cerebral Performance Category score of 3-5 at hospital discharge. Results: Twelve (25.5%) patients had abnormal findings on computed tomography of the brain. A poor neurologic outcome was demonstrated in 22 (46.8%) patients. The NSE level at 72 h after ECPR showed the best prediction power for a poor neurologic outcome compared with NSE at 24 and 48 h. A cutoff value exceeding 61.9 µg/L for NSE at 72 h yielded an area under the curve (AUC) of 0.791 for predicting poor neurologic outcomes and exceeding 62.1 µg/L with an AUC of 0.838 for 30-day mortality. Conclusions: NSE levels at 72 h after ECPR appear to be a reliable biomarker for predicting poor neurologic outcomes and 30-day mortality in ECPR patients.

Advanced age and neurological recovery in elderly patients with out-of-hospital cardiac arrest treated with targeted temperature management: a nationwide population­based registry study 2016-2020.

The likelihood of neurological recovery after out-of-hospital cardiac arrest (OHCA) may be influenced by advanced age. This study aims to evaluate the impact of advanced age on neurological recovery in elderly OHCA survivors treated with targeted temperature management (TTM). This retrospective observational study, using a nationwide population-based OHCA registry, was conducted from January 2016 to December 2020. Non-traumatic elderly (≥ 65 years) comatose OHCA survivors treated with TTM were categorized according to age (65-69, 70-74, 75-79, and ≥ 80 years). Among 23,336 admitted OHCA patients, 3,398 were treated with TTM. Excluding 2,033 non-elderly patients, 1,365 were analyzed. Among the four groups, the rate of good neurological outcomes decreased by advanced age (24.2%, 16.1%, 11.4%, and 5.9%, respectively), which was also observed after subgroup analysis based on the initial shockable (40.6%, 31.5%, 28.6%, and 14.9%, respectively) and non-shockable rhythm (10.6%, 7.2%, 4.1%, and 3.4%, respectively). Multivariate analysis showed the adjusted odds ratio (aOR) for good neurological outcome decreased as age increased (65-69: reference, 70-74: aOR 0.70, 75-79: aOR 0.49, and ≥ 80 years: aOR 0.25). The optimal age cutoffs for good outcomes in elderly OHCA survivors with shockable and non-shockable rhythm were 77 and 72 years, respectively. The neurologic recovery rate in OHCA survivors treated with TTM gradually decreased with increasing age. However, even patients aged ≥ 80 years with shockable rhythm had a good neurologic outcome of 14.9% compared with patients aged 65-69 years with non-shockable rhythm (10.6%).

Exploratory factor analysis yields grouping of brain injury biomarkers significantly associated with outcomes in neonatal and pediatric ECMO.

In this two-center prospective cohort study of children on ECMO, we assessed a panel of plasma brain injury biomarkers using exploratory factor analysis (EFA) to evaluate their interplay and association with outcomes. Biomarker concentrations were measured daily for the first 3 days of ECMO support in 95 participants. Unfavorable composite outcome was defined as in-hospital mortality or discharge Pediatric Cerebral Performance Category > 2 with decline ≥ 1 point from baseline. EFA grouped 11 biomarkers into three factors. Factor 1 comprised markers of cellular brain injury (NSE, BDNF, GFAP, S100ß, MCP1, VILIP-1, neurogranin); Factor 2 comprised markers related to vascular processes (vWF, PDGFRß, NPTX1); and Factor 3 comprised the BDNF/MMP-9 cellular pathway. Multivariable logistic models demonstrated that higher Factor 1 and 2 scores were associated with higher odds of unfavorable outcome (adjusted OR 2.88 [1.61, 5.66] and 1.89 [1.12, 3.43], respectively). Conversely, higher Factor 3 scores were associated with lower odds of unfavorable outcome (adjusted OR 0.54 [0.31, 0.88]), which is biologically plausible given the role of BDNF in neuroplasticity. Application of EFA on plasma brain injury biomarkers in children on ECMO yielded grouping of biomarkers into three factors that were significantly associated with unfavorable outcome, suggesting future potential as prognostic instruments.

Correlation between early computed tomography findings and neurological outcome in pediatric traumatic brain injury patients.

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Head computed tomography (CT) is frequently utilized for evaluating trauma-related characteristics, selecting treatment options, and monitoring complications in the early stages. This study assessed the relationship between cranial CT findings and early and late neurological outcomes in pediatric TBI patients admitted to the pediatric intensive care unit (PICU). The study included children aged 1 month to 18 years who were admitted to the PICU due to TBI between 2014 and 2020. Sociodemographic data, clinical characteristics, and cranial CT findings were analyzed. Patients were categorized based on their Glasgow Coma Scale (GCS) score. Of the 129 patients, 83 (64%) were male, and 46 (36%) were female, with a mean age of 6.8 years. Falls (n = 51, 39.5%) and in-vehicle traffic accidents (n = 35, 27.1%) were the most common trauma types observed. Normal brain imaging findings were found in 62.7% of the patients, while 37.3% exhibited intracranial pathology. Hemorrhage was the most frequent CT finding. Severe TBI (n = 26, p = 0.032) and mortality (n = 9, p = 0.017) were more prevalent in traffic accidents. The overall mortality rate in the study population was 10.1%. In children with TBI, cranial CT imaging serves as an essential initial method for patients with neurological manifestations. Particularly, a GCS score of ≤ 8, multiple hemorrhages, diffuse cerebral edema, and intraventricular bleeding are associated with sequelae and mortality.

Cumulative epinephrine dose during cardiac arrest and neurologic outcome after extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Epinephrine is recommended without an apparent ceiling dosage during cardiac arrest. However, excessive alpha- and beta-adrenergic stimulation may contribute to unnecessarily high aortic afterload, promote post-arrest myocardial dysfunction, and result in cerebral microvascular insufficiency in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). METHODS: This was a retrospective cohort study of adults (≥ 18 years) who received ECPR at large academic ECMO center from 2018 to 2022. Patients were grouped based on the amount of epinephrine given during cardiac arrest into low (≤ 3 mg) and high (> 3 mg) groups. The primary endpoint was neurologic outcome at hospital discharge, defined by cerebral performance category (CPC). Multivariable logistic regression was used to assess the relationship between cumulative epinephrine dosage during arrest and neurologic outcome. RESULTS: Among 51 included ECPR cases, the median age of patients was 60 years, and 55% were male. The mean cumulative epinephrine dose administered during arrest was 6.2 mg but ranged from 0 to 24 mg. There were 18 patients in the low-dose (≤ 3 mg) and 25 patients in the high-dose (> 3 mg) epinephrine groups. Favorable neurologic outcome at discharge was significantly greater in the low-dose (55%) compared to the high-dose (24%) group (p = 0.025). After adjusting for age, those who received higher doses of epinephrine during the arrest were more likely to have unfavorable neurologic outcomes at hospital discharge (odds ratio 4.6, 95% CI 1.3, 18.0, p = 0.017). CONCLUSION: After adjusting for age, cumulative epinephrine doses above 3 mg during cardiac arrest may be associated with unfavorable neurologic outcomes after ECPR and require further investigation.

Outcome of partial agenesis of corpus callosum.

BACKGROUND: The diagnosis of corpus callosum anomalies by prenatal ultrasound has improved over the last decade because of improved imaging techniques, scanning skills, and the routine implementation of transvaginal neurosonography. OBJECTIVE: Our aim was to investigate all cases of incomplete agenesis of the corpus callosum and to report the sonographic characteristics, the associated anomalies, and the perinatal outcomes. STUDY DESIGN: We performed a retrospective analysis of cases from January 2007 to December 2017 with corpus callosum anomalies, either referred for a second opinion or derived from the prenatal ultrasound screening program in a single tertiary referral center. Cases with complete agenesis were excluded from the analysis. Standardized investigation included a detailed fetal ultrasound including neurosonogram, fetal karyotyping (standard karyotype or array comparative genomic hybridization) and fetal magnetic resonance imaging. The pregnancy outcome was collected, and pathologic investigation in case of termination of the pregnancy or fetal or neonatal loss was compared with the prenatal findings. The pregnancy and fetal or neonatal outcomes were reported. The neurologic assessment was conducted by a pediatric neurologist using the Bayley Scales of Infant Development-II and the standardized Child Development Inventory when the Bayley investigation was unavailable. RESULTS: Corpus callosum anomalies were diagnosed in 148 cases during the study period, 62 (41.9%) of which were excluded because of complete agenesis, and 86 fetuses had partial agenesis (58.1%). In 20 cases, partial agenesis (23.2%) was isolated, whereas 66 (76.7%) presented with different malformations among which 29 cases (43.9%) were only central nervous system lesions, 21 cases (31.8%) were non-central nervous system lesions, and 16 cases (24.3%) had a combination of central nervous system and non-central nervous system lesions. The mean gestational age at diagnosis for isolated and non-isolated cases was comparable (24.29 [standard deviation, 5.05] weeks and 24.71 [standard deviation, 5.35] weeks, respectively). Of the 86 pregnancies with partial agenesis, 46 patients opted for termination of the pregnancy. Neurologic follow-up data were available for 35 children. The overall neurologic outcome was normal in 21 of 35 children (60%); 3 of 35 (8.6%) showed mild impairment and 6 of 35 (17.1%) showed moderate impairment. The remaining 5 of 35 (14.3%) had severe impairment. The median duration of follow-up for the isolated form was 45.6 months (range, 36-52 months) and 73.3 months (range, 2-138 months) for the nonisolated form. CONCLUSION: Partial corpus callosum agenesis should be accurately investigated by neurosonography and fetal magnetic resonance imaging to describe its morphology and the associated anomalies. Genetic anomalies are frequently present in nonisolated cases. Efforts must be taken to improve ultrasound diagnosis of partial agenesis and to confirm its isolated nature to enhance parental counseling. Although 60% of children with prenatal diagnosis of isolated agenesis have a favorable prognosis later in life, they often have mild to severe disabilities including speech disorders at school age and behavior and motor deficit disorders that can emerge at a later age.

Early Postoperative Neurologic Events Are Associated With Worse Outcome and Fatal Midterm Survival After Adult Heart Transplantation.

Background Neurologic events during primary stay in heart transplant (HTx) recipients may be associated with reduced outcome and survival, which we aim to explore with the current study. Methods and Results We screened and included all patients undergoing HTx in our center between September 2010 and December 2022 (n=268) and checked for the occurrence of neurologic events within their index stay. Neurologic events were defined as ischemic stroke, hemorrhage, hypoxic ischemic injury, or acute symptomatic neurologic dysfunction without central nervous system injury. The cohort was then divided into recipients with (n=33) and without (n=235) neurologic events after HTx. Using a multivariable Cox regression model, the association of neurologic events after HTx and survival was assessed. Recipients with neurologic events displayed a longer intensive care unit stay (30 versus 16 days; P=0.009), longer mechanical ventilation (192 versus 48 hours; P<0.001), and higher need for blood transfusion, and need for hemodialysis after HTx was substantially higher (81% versus 55%; P=0.01). Resternotomy (36% versus 26%; P=0.05) and mechanical life support (extracorporeal life support) after HTx (46% versus 24%; P=0.02) were also significantly higher in patients with neurologic events. Covariable-adjusted multivariable Cox regression analysis revealed a significant independent association of neurologic events and increased 30-day (hazard ratio [HR], 2.5 [95% CI, 1.0-6.0]; P=0.049), 1-year (HR, 2.2 [95% CI, 1.1-4.3]; P=0.019), and overall (HR, 2.5 [95% CI, 1.5-4.2]; P<0.001) mortality after HTx and reduced Kaplan-Meier survival up to 5 years after HTx (P<0.001). Conclusions Neurologic events after HTx were strongly and independently associated with worse postoperative outcome and reduced survival up to 5 years after HTx.

Mean arterial pressure (MAP) augmentation in traumatic spinal cord injuries: Early hyperperfusion treatment influences neurologic outcomes.

CONTEXT: Hyperperfusion therapy, mean arterial blood pressure (MAP) > 85 mmHg, is a recommended treatment of blunt traumatic spinal cord injury (SCI). We hypothesized the first 24 h of MAP augmentation would be most influential on neurological outcomes. DESIGN: This retrospective study from a level 1 urban trauma center dating 1/2017 to 12/2019 included all blunt traumatic spinal cord injured patients receiving hyperperfusion therapy. Patients were grouped as "No improvement" vs "Improvement" measured by change in American Spinal Injury Association (ASIA) score during their hospitalization. MAP values for the first 12, first 24 and last 72 h were compared between the two groups; P < 0.05 was significant. RESULTS: After exclusions, 96 patients underwent hyperperfusion therapy for blunt traumatic SCI, 82 in the No Improvement and 14 in the Improvement group. Groups had similar treatment durations (95.6 and 96.7 h, P = 0.66) and ISS (20.5 and 23, P = 0.45). The area under the curve, calculation, to account for time less than goal and MAP difference from goal, in the No Improvement group was significantly higher (lower and more time below MAP goal) compared to the Improvement group for the first 12 h (40.3 v. 26.1 P = 0.03) with similar findings in the subsequent 12 h of treatment (13-24 h; 62.2 vs 43, P = 0.09). There was no difference between the groups in the subsequent 72 h (25-96 h; 156.4 vs 136.6, P = 0.57). CONCLUSIONS: Hyperperfusion to the spinal cord in the first 12 h correlated significantly with improved neurological outcome in SCI patients.

Comparison of Prognostic Performance between Procalcitonin and Procalcitonin-to-Albumin Ratio in Post Cardiac Arrest Syndrome.

(1) Background: Post-cardiac arrest syndrome (PCAS) is a type of global ischemic reperfusion injury that occurs after the return of spontaneous circulation (ROSC). The procalcitonin to albumin ratio (PAR) has been studied as an independent prognostic factor of various diseases. There are no previous studies of PAR in patients with PCAS. We assessed if PAR is more effective than procalcitonin (PCT) in predicting prognosis for patients with PCAS. (2) Methods: This retrospective cohort study included a total of 187 patients with PCAS after non-traumatic out-of-hospital cardiac arrest (OHCA) between January 2016 and December 2020. Multivariate logistic regression analysis was conducted to assess the association between PAR and PCAS prognosis. The predictive performance of PAR was compared with PCT via the receiver-operating characteristic (ROC) analysis and DeLong test.; (3) Results: PAR at 24 and 48 h after hospital admission were independently associated with one-month neurological outcome (OR: 1.167, 95% CI: 1.023-1.330; OR: 1.077, 95% CI: 1.012-1.146, p < 0.05). By ROC analysis, PAR showed better performance over PCT at 48 h after admission in predicting one-month CPC (0.763 vs. 0.772, p = 0.010). (4) Conclusions: Our findings suggest that PAR at 48 h after admission is more effective in predicting a one-month neurological outcome than PCT at 48 h after admission in patients with PCAS after OHCA.

High-normal versus low-normal mean arterial pressure thresholds in critically ill patients: a systematic review and meta-analysis of randomized trials.

PURPOSE: Targeted blood pressure thresholds remain unclear in critically ill patients. Two prior systematic reviews have not shown differences in mortality with a high mean arterial pressure (MAP) threshold, but there have been new studies published since. Thus, we conducted an updated systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the effect of a high-normal vs low-normal MAP on mortality, favourable neurologic outcome, need for renal replacement therapy, and adverse vasopressor-induced events in critically ill patients. SOURCE: We searched six databases from inception until 1 October 2022 for RCTs of critically ill patients targeted to either a high-normal vs a low-normal MAP threshold for at least 24 hr. We assessed study quality using the revised Cochrane risk-of-bias 2 tool and the risk ratio (RR) was used as the summary measure of association. We used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence. PRINCIPAL FINDINGS: We included eight RCTs with 4,561 patients. Four trials were conducted in patients following out-of-hospital cardiac arrest, two in patients with distributive shock requiring vasopressors, one in patients with septic shock, and one in patients with hepatorenal syndrome. The pooled RRs for mortality (eight RCTs; 4,439 patients) and favourable neurologic outcome (four RCTs; 1,065 patients) were 1.06 (95% confidence interval [CI], 0.99 to 1.14; moderate certainty) and 0.99 (95% CI, 0.90 to 1.08; moderate certainty), respectively. The RR for the need for renal replacement therapy (four RCTs; 4,071 patients) was 0.97 (95% CI, 0.87 to 1.08; moderate certainty). There was no statistical between-study heterogeneity across all outcomes. CONCLUSION: This updated systematic review and meta-analysis of RCTs found no differences in mortality, favourable neurologic outcome, or the need for renal replacement therapy between critically ill patients assigned to a high-normal vs low-normal MAP target. STUDY REGISTRATION: PROSPERO (CRD42022307601); registered 28 February 2022.

RéSUMé: OBJECTIF: Les seuils de pression artérielle ciblés demeurent incertains chez les patient·es gravement malades. Deux revues systématiques antérieures n'ont pas montré de différences dans la mortalité avec un seuil élevé de pression artérielle moyenne (PAM), mais de nouvelles études ont été publiées depuis. Pour cette raison, nous avons réalisé une revue systématique mise à jour et une méta-analyse d'études randomisées contrôlées (ERC) comparant l'effet d'une PAM normale élevée vs normale faible sur la mortalité, les devenirs neurologiques favorables, la nécessité d'un traitement substitutif de l'insuffisance rénale et les événements indésirables induits par les vasopresseurs chez les patient·es gravement malades. SOURCES: Nous avons effectué des recherches dans six bases de données depuis leur création jusqu'au 1er octobre 2022 pour trouver des ERC portant sur des patient·es gravement malades chez lesquel·les un seuil de PAM normale élevée ou normale faible a été ciblé pendant au moins 24 heures. Nous avons évalué la qualité des études à l'aide de l'outil de risque de biais 2 révisé de Cochrane, et le risque relatif (RR) a été utilisé comme mesure sommaire de l'association. Nous avons utilisé le système de notation GRADE (Grading of Recommendations Assessment, Development, and Evaluation) pour évaluer la certitude des données probantes. CONSTATATIONS PRINCIPALES: Nous avons inclus huit ERC portant sur 4561 personnes traitées. Quatre études ont été menées chez des patient·es à la suite d'un arrêt cardiaque hors de l'hôpital, deux chez des patient·es présentant un choc distributif nécessitant des vasopresseurs, une chez des patient·es présentant un choc septique et une chez des patient·es atteint·es d'un syndrome hépato-rénal. Les RR combinés pour la mortalité (huit ERC; 4439 personnes) et les devenirs neurologiques favorables (quatre ERC; 1065 personnes) étaient respectivement de 1,06 (intervalle de confiance [IC] à 95 %, 0,99 à 1,14; certitude modérée) et de 0,99 (IC 95 %, 0,90 à 1,08; certitude modérée). Le RR pour le besoin de traitement substitutif de l'insuffisance rénale (quatre ERC; 4071 patient·es) était de 0,97 (IC 95 %, 0,87 à 1,08; certitude modérée). Il n'y avait pas d'hétérogénéité statistique entre les études pour tous les critères d'évaluation. CONCLUSION: Ces revue systématique et méta-analyse mises à jour des ERC n'ont révélé aucune différence dans la mortalité, les devenirs neurologiques favorables ou la nécessité d'un traitement substitutif de l'insuffisance rénale entre les patient·es gravement malades assigné·es à une cible de PAM normale élevée vs normale faible. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42022307601); enregistrée le 28 février 2022.

Hypothermia may reduce mortality and improve neurologic outcomes in adult patients treated with VA-ECMO: A systematic review and meta-analysis.

BACKGROUND: VA-ECMO can greatly reduce mortality in critically ill patients, and hypothermia attenuates the deleterious effects of ischemia-reperfusion injury. We aimed to study the effects of hypothermia on mortality and neurological outcomes in VA-ECMO patients. METHODS: A systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases was performed from the earliest available date to 31 December 2022. The primary outcome was discharge or 28-day mortality and favorable neurological outcomes in VA-ECMO patients, and the secondary outcome was bleeding risk in VA-ECMO patients. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Based on the heterogeneity assessed by the I2 statistic, meta-analyses were performed using random or fixed-effects models. GRADE methodology was used to rate the certainty in the findings. RESULTS: A total of 27 articles (3782 patients) were included. Hypothermia (33-35 °C) lasting at least 24 h can significantly reduce discharge or 28-day mortality (OR, 0.45; 95% CI, 0.33-0.63; I2 = 41%) and significantly improve favorable neurological outcomes (OR, 2.08; 95% CI, 1.66-2.61; I2 = 3%) in VA-ECMO patients. Additionally, there was no risk associated with bleeding (OR, 1.15; 95% CI, 0.86-1.53; I2 = 12%). In our subgroup analysis according to in-hospital or out-of-hospital cardiac arrest, hypothermia reduced short-term mortality in both VA-ECMO-assisted in-hospital (OR, 0.30; 95% CI, 0.11-0.86; I2 = 0.0%) and out-of-hospital cardiac arrest (OR, 0.41; 95% CI, 0.25-0.69; I2 = 52.3%). Out-of-hospital cardiac arrest patients assisted by VA-ECMO for favorable neurological outcomes were consistent with the conclusions of this paper (OR, 2.10; 95% CI, 1.63-2.72; I2 = 0.5%). CONCLUSIONS: Our results show that mild hypothermia (33-35 °C) lasting at least 24 h can greatly reduce short-term mortality and significantly improve favorable short-term neurologic outcomes in VA-ECMO-assisted patients without bleeding-related risks. As the grade assessment indicated that the certainty of the evidence was relatively low, hypothermia as a strategy for VA-ECMO-assisted patient care may need to be treated with caution.

A four year experience treating incomplete thoracolumbar spine injuries in an East African country.

Background: Traumatic spine injuries are one of the most common causes of disability and mortality. Objective: To assess post op neurologic status in patients with incomplete thoracic and lumbar spine injuries at two teaching hospitals in Addis Ababa, Ethiopia. Methods: Institution based retrospective cross-sectional study was conducted among 60 hospitalized patients in these hospitals from February 1, 2017-January 31, 2021. Results: Forty five (75.0%) of the study participants were males. The mean age was 30.77 years (range: 12-65 year). Only 8(13.3%) patients were operated within 3 days of trauma. The most common injury site was the thoracolumbar junction (T11-L2) in 80.0%. Significant number of patients (56.7%) had sphincters dysfunction. Pedicle screw fixation with or without laminectomy was performed in 98.3%. After minimum six month follow up, 37(61.7%) patients had access to the physiotherapy. Thirty seven (61.7%) patients were non ambulatory (AIS B and C) at presentation, of which 29 (78.4%) were ambulatory on the follow-up. Overall, 54(90%) patients had neurologic improvement on the follow up and 37(61.7%) returned to work. Preoperative neurologic status and sphincter function were found to be significantly associated with treatment outcome with P value 0 .000 and 0.002 respectively. Conclusion: This study shows despite limited availability of post op physiotherapy, significant number of patientsreturned to work post-surgery. Preoperative neurologic function was an independent predictor of post-operative outcome.

Are serial neuron-specific enolase levels associated with neurologic outcome of ECPR patients: A retrospective multicenter observational study.

AIM OF THE STUDY: This study aims to evaluate whether neuron-specific enolase (NSE) level at 48 h after extracorporeal cardiopulmonary resuscitation (ECPR) is associated with neurologic outcomes at 6 months after hospital discharge. METHODS: This was a retrospective, multicenter, observational study of adult patients who received ECPR between May 2010 and December 2016. In the two hospitals involved in this study, NSE measurements were a routine part of the protocol for patients who received ECPR. Serial NSE levels were measured in all patients with ECPR. NSE levels were measured 24, 48, and 72 h after ECPR. The primary outcome was Cerebral Performance Categories (CPC) scale at 6 months after hospital discharge according to NSE levels at 48 h after ECPR. RESULTS: At follow-up 6 months after hospital discharge, favorable neurologic outcomes of CPC 1 or 2 were observed in 9 (36.0%) of the 25 patients, and poor neurologic outcomes of CPC 3, 4, or 5 were observed in 16 (64%) patients. NSE levels at 24 h in the favorable and poor neurologic outcome groups were 58.3 (52.5-73.2) µg/L and 64.2 (37.9-89.8) µg/L, respectively (p = 0.95). NSE levels at 48 h in the favorable and poor neurologic outcome groups were 52.1 (22.3-64.9) µg/L and 302.0 (62.8-360.2) µg/L, respectively (p = 0.01). NSE levels at 72 h were 37.2 (12.5-53.2) µg/L and 240.9 (75.3-370.0) µg/L, respectively (p < 0.01). In receiver operating characteristic (ROC) curve analysis, as the predictor of poor outcome, the optimal cut-off value for NSE level at 48 h was 140.5 µg/L, and the area under the curve (AUC) was 0.844 (p < 0.01). The optimal cut-off NSE level at 72 h was 53.2 µg/L, and the AUC was 0.897 (p < 0.01). CONCLUSIONS: NSE level at 72 h displayed the highest association with neurologic outcome after ECPR, and NSE level at 48 h was also associated with neurologic outcome after ECPR.

Clinical outcomes following out-of-hospital cardiac arrest: The minute-by-minute impact of bystander cardiopulmonary resuscitation.

AIMS: The time-dependent prognostic role of bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients has not been described with great precision, especially for neurologic outcomes. Our objective was to assess the association between bystander CPR, emergency medical service (EMS) response time, and OHCA patients' outcomes. METHODS: This cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registries. Bystander-witnessed adult OHCA treated by EMS were included. The primary outcome was survival to hospital discharge and secondary outcome was survival with a good neurologic outcome (modified Rankin scale 0-2). Multivariable logistic regression models were used to assess the associations and interactions between bystander CPR, EMS response time and clinical outcomes. RESULTS: Out of 229,637 patients, 41,012 were included (18,867 [46.0%] without bystander CPR and 22,145 [54.0%] with bystander CPR). Bystander CPR was independently associated with higher survival (adjusted odds ratio [AOR] = 1.70 [95%CI 1.61-1.80]) and survival with a good neurologic outcome (AOR = 1.87 [95%CI 1.70-2.06]), while longer EMS response times were independently associated with lower survival to hospital discharge (each additional minute of EMS response time: AOR = 0.92 [95%CI 0.91-0.93], p < 0.001) and lower survival with a good neurologic outcome (AOR = 0.88 [95%CI 0.86-0.89], p < 0.001). There was no interaction between bystander CPR and EMS response time's association with survival (p = 0.12) and neurologic outcomes (p = 0.65). CONCLUSIONS: Although bystander CPR is associated with an immediate increase in odds of survival and of good neurologic outcome for OHCA patients, it does not influence the negative association between longer EMS response time and survival and good neurologic outcome.

Clinical Characteristics, Imaging Findings, and Outcomes of Cerebral Air Embolism.

BACKGROUND: Arterial cerebral air embolism (CAE) is an uncommon but potentially catastrophic event. Patients can present with focal neurologic deficits, seizures, or coma. They may be treated with hyperbaric oxygen therapy. We review the causes, radiographic and clinical characteristics, and outcomes of patients with CAE. METHODS: We performed a retrospective chart review via an existing institutional database at Mayo Clinic to identify patients with arterial CAE. Demographic data, clinical characteristics, and diagnostic studies were extracted and classified on predefined criteria of diagnostic confidence, and descriptive and univariate analysis was completed. RESULTS: Fifteen patients met criteria for inclusion in our study. Most presented with focal deficits (80%) and/or coma (53%). Seven patients (47%) had seizures, including status epilepticus in one (7%). Five presented with increased muscle tone at the time of the event (33%). Computed tomography (CT) imaging was insensitive for the detection of CAE, only identifying free air in 4 of 13 who underwent this study. When obtained, magnetic resonance imaging typically showed multifocal areas of restricted diffusion. Six patients (40%) were treated with hyperbaric oxygen therapy. Age, Glasgow Coma Scale score at nadir, and use of hyperbaric oxygen therapy were not associated with functional outcome at 1 year in our cohort. Twenty-six percent of patients had a modified Rankin scale score of 0 one year after the event, and functional improvement over time was common after discharge. CONCLUSIONS: A high index of clinical suspicion is needed to identify patients with CAE because of low sensitivity of free air on CT imaging and nonspecific clinical presentation. Acute alteration of consciousness, seizures, and focal signs occur frequently. Because improvement over time is possible even among patients with severe presentation, early prognostication should be approached with caution.

Association between metformin and survival outcomes in in-hospital cardiac arrest patients with diabetes.

INTRODUCTION: Metformin has shown cardioprotective and neuroprotective effects in cardiac arrest and ischemia-reperfusion injury animal models. Therefore, this study aimed to determine the association between diabetes medication and survival outcomes in in-hospital cardiac arrest (IHCA) patients with type 2 DM (T2DM). METHODS: This retrospective observational study included adult IHCA patients with T2DM between April 2017 and March 2022. The variable of interest was administration of diabetes medications within 24 h before cardiac arrest. Multivariable logistic regression analysis was performed. RESULTS: In the 377 included patients, administration of metformin within 24 h before IHCA was associated with a higher rate of survival to discharge and good neurologic outcome (41.5% vs 11.7%, P < 0.001 and 18.9% vs 6.2%, P = 0.004, respectively). Administration of metformin within 24 h before IHCA was independently associated with survival to discharge and good neurologic outcome (aOR: 5.37, 95% CI: 2.13-13.53, P < 0.001 and aOR: 3.57, 95% CI: 1.14-11.17, P = 0.029). The rate of survival to discharge was the highest in patients who were administered 500-1000 mg/day metformin (P < 0.001). CONCLUSIONS: In IHCA patients with T2DM, administration of metformin within 24 h before IHCA was independently associated with survival to discharge.

Long-Term Functional Outcome and Quality of Life After Surgical Evacuation of Spontaneous Supratentorial Intracerebral Hemorrhage: Results from a Swedish Nationwide Cohort.

OBJECTIVE: To investigate long-term survival, neurologic outcome, and quality of life in patients with spontaneous supratentorial intracerebral hemorrhage (ICH) treated with craniotomy and hematoma evacuation. METHODS: A nationwide multicenter retrospective analysis of 341 patients who underwent craniotomy and evacuation of supratentorial ICH between January 1, 2011, and December 31, 2015, was performed. Baseline characteristics associated with 6-month mortality and long-term mortality were investigated. Survivors received a questionnaire about their state of health from which EuroQol 5D (EQ-5D) and modified Rankin scale (mRS) were obtained. Predictors of mortality, unfavorable outcome, and life quality were analyzed. RESULTS: The mean follow-up time was 55.2 months. Predictors of 6-month mortality in multiple regression analysis were age ≥75 years, previous myocardial infarction, lower level of consciousness, and mechanical ventilation. Predictors of long-term mortality were higher age and mechanical ventilation. At follow-up, 49.5% of survivors had a favorable neurologic outcome (mRS ≤3). Predictors of an unfavorable functional outcome were higher age and ICH volume ≥50 mL. The mean EQ-5D health index was 0.719, and the mean EQ-5D visual analog scale score was 53.9. In multiple regression, only a higher mRS score was significantly associated with worse life quality. CONCLUSIONS: Knowledge about survival, functional outcome, and life quality as well as their predictors in this specific patient group is previously primarily described in short-term follow-up. This multicenter study provides novel information in the long-term perspective, which is important for improved surgical decision-making and prognostication.

Epidemiology and clinical outcomes of poisoning-induced cardiac arrest in Japan: Retrospective analysis of a nationwide registry.

BACKGROUND: Poisoning is an important cause of out-of-hospital cardiac arrest which can be challenging to manage. Neurological outcomes after poisoning-induced out-of-hospital cardiac arrest (POHCA) are yet to be fully elucidated. This retrospective cohort study sought to describe the characteristics of POHCA, and identify factors associated with favourable neurologic outcomes. METHODS: Cardiac arrests recorded in the "All Japan Utstein Registry" from 1 January 2012 to 31 December 2017 were included. A descriptive analysis of the characteristics of POHCA and non-POHCA patients was performed. Neurological outcomes were compared between the POHCA and non-POHCA groups using logistic regression analysis. Subgroup analysis was performed for patients who underwent prolonged resuscitation. RESULTS: Compared to non-POHCA patients (n = 665,262), POHCA patients (n = 1,868) were younger (median age, 80 vs 51 years) and had a lower likelihood of having a witness, bystander cardiopulmonary resuscitation, and an initial shockable rhythm. Multivariable logistic regression analysis showed that POHCA was associated with favourable neurologic outcomes (odds ratio 1.54, 95 % confidence interval 1.19-2.01, p = 0.001). Among patients who received > 30 min of resuscitation, neurologic outcomes were similar in those with POHCA and non-POHCA (favourable neurologic outcome, 1.03 % vs 0.98 %, p = 0.87). CONCLUSIONS: POHCA is associated with favourable neurological outcomes and requires aggressive resuscitation. However, in patients who required prolonged resuscitation, the outcomes of POHCA were not different from those of non-POHCA. The decision to perform prolonged resuscitation should be guided on a case-by-case basis based on a range of factors.

The Prognostic Value of Optic Nerve Sheath Diameter/Eyeball Transverse Diameter Ratio in the Neurological Outcomes of Out-of-Hospital Cardiac Arrest Patients.

Background and objectives: The optic nerve sheath diameter (ONSD) is indicative of elevated intracranial pressure. However, the usefulness of the ONSD for predicting neurologic outcomes in cardiac arrest survivals has been debatable. Reportedly, the ONSD/eyeball transverse diameter (ETD) ratio is a more reliable marker for identifying intracranial pressure than sole use of ONSD. Materials and Methods: This retrospective study aimed to investigate the prognostic value of the ONSD/ETD ratio in out-of-hospital cardiac arrest (OHCA) patients. We studied the brain computed tomography scans of adult OHCA patients with return of spontaneous circulation, who visited a single hospital connected with a Korean university between January 2015 and September 2020. We collected baseline characteristics and patient information from electronic medical records and ONSD and ETD were measured by two physicians with a pre-defined protocol. According to their neurologic outcome upon hospital discharge, patients were divided into good neurologic outcome (GNO; cerebral performance category [CPC] 1-2) and poor neurologic outcome (PNO; CPC 3-5) groups. We evaluated the ONSD/ETD ratio between the GNO and PNO groups to establish its prognostic value for neurologic outcomes. Results: Of the 100 included patients, 28 had GNO. Both the ONSD and ETD were not significantly different between the two groups (ONSD, 5.48 mm vs. 5.66 mm, p = 0.054; ETD, 22.98 mm vs. 22.61 mm, p = 0.204). However, the ONSD/ETD ratio was significantly higher in the PNO group in the univariate analysis (0.239 vs. 0.255, p = 0.014). The area under the receiver operating characteristic curve of ONSD/ETD ratio for predicting PNO was 0.66 (95% confidence interval, 0.56-0.75; p = 0.006). There was no independent relationship between the ONSD/ETD ratio and PNO in multivariate analysis (aOR = 0.000; p = 0.173). Conclusions: The ONSD/ETD ratio was more reliable than sole use of ONSD and might be used to predict neurologic outcomes in OHCA survivors.