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Coma and disordered consciousness are common manifestations of acute neurological conditions and are among the most pervasive and challenging aspects of treatment in neurocritical care. Gaps exist in patient assessment, outcome prognostication, and treatment directed specifically at improving consciousness and cognitive recovery. In 2019, the Neurocritical Care Society (NCS) launched the Curing Coma Campaign in order to address the "grand challenge" of improving the management of patients with coma and decreased consciousness. One of the first steps was to bring together a Scientific Advisory Council including coma scientists, neurointensivists, neurorehabilitationists, and implementation experts in order to address the current scientific landscape and begin to develop a framework on how to move forward. This manuscript describes the proceedings of the first Curing Coma Campaign Scientific Advisory Council meeting which occurred in conjunction with the NCS Annual Meeting in October 2019 in Vancouver. Specifically, three major pillars were identified which should be considered: endotyping of coma and disorders of consciousness, biomarkers, and proof-of-concept clinical trials. Each is summarized with regard to current approach, benefits to the patient, family, and clinicians, and next steps. Integration of these three pillars will be essential to the success of the Curing Coma Campaign as will expanding the "curing coma community" to ensure broad participation of clinicians, scientists, and patient advocates with the goal of identifying and implementing treatments to fundamentally improve the outcome of patients. [ABSTRACT FROM AUTHOR]

The Neurocritical Care Society and the Society of Critical Care Medicine have worked together to create a perspective regarding the Standards of Neurologic Critical Care Units (Moheet et al. in Neurocrit Care 29:145-160, 2018). The most neurologically ill or injured patients warrant the highest standard of care available; this supports the need for defining and establishing specialized neurological critical care units. Rather than interpreting the Standards as being exclusionary, it is most appropriate to embrace them in the setting of team-based care. Since there are many more patients than there are highly specialized beds, collaborative care and appropriate transfer agreements are essential in promoting excellent patient outcomes. This viewpoint addresses areas of clarification and emphasizes the need for collegiality and partnership in delivering the best specialty critical care to our patients. [ABSTRACT FROM AUTHOR]

Background: Early brain injury (EBI) following aneurysmal subarachnoid hemorrhage (SAH) is an important predictor of poor functional outcome, yet the underlying mechanism is not well understood. Animal studies suggest that platelet activation and inflammation with subsequent microthrombosis and ischemia may be a mechanism of EBI.Methods: A prospective, hypothesis-driven study of spontaneous, SAH patients and controls was conducted. Platelet activation [thromboelastography maximum amplitude (MA)] and inflammation [C-reactive protein (CRP)] were measured serially over time during the first 72 h following SAH onset. Platelet activation and inflammatory markers were compared between controls and SAH patients with mild [Hunt-Hess (HH) 1-3] versus severe (HH 4-5) EBI. The association of these biomarkers with 3-month functional outcomes was evaluated.Results: We enrolled 127 patients (106 SAH; 21 controls). Platelet activation and CRP increased incrementally with worse EBI/HH grade, and both increased over 72 h (all P < 0.01). Both were higher in severe versus mild EBI (MA 68.9 vs. 64.8 mm, P = 0.001; CRP 12.5 vs. 1.5 mg/L, P = 0.003) and compared to controls (both P < 0.003). Patients with delayed cerebral ischemia (DCI) had more platelet activation (66.6 vs. 64.9 in those without DCI, P = 0.02) within 72 h of ictus. At 3 months, death or severe disability was more likely with higher levels of platelet activation (mRS4-6 OR 1.18, 95 % CI 1.05-1.32, P = 0.007) and CRP (mRS4-6 OR 1.02, 95 % CI 1.00-1.03, P = 0.041).Conclusions: Platelet activation and inflammation occur acutely after SAH and are associated with worse EBI, DCI and poor 3-month functional outcomes. These markers may provide insight into the mechanism of EBI following SAH. [ABSTRACT FROM AUTHOR]

As authors of the proceedings of the first Curing Coma Campaign Scientific Advisory Council (SAC) Meeting [[1]], we were excited to read the response from Lazaridis and colleagues. In order to meet this "grand challenge", the overall Curing Coma Campaign has been initially organized into a scientific advisory section along with multiple operational modules to address the overarching goals of: (1) understanding coma in ICU patients, (2) impacting care of coma patients in the acute and recovery settings, and (3) developing the community of coma and consciousness clinical and research collaborators to study, implement, and disseminate knowledge and interventions widely. Original article by Provencio JJ, et al.: The Curing Coma Campaign: Framing Initial Scientific Challenges-Proceedings of the First Curing Coma Campaign Scientific Advisory Council Meeting. [Extracted from the article]

Introduction: Effective treatment for severe ischemic stroke continues to be largely an unmet medical need. Using a nonvascular (paravascular cerebrospinal fluid) pathway to provide oxygen and nutrients to ischemic tissues may be a means of treating this disease. The primary objective of this study was to evaluate the safety and technical feasibility of ventriculo-lumbar perfusion with the oxygenated fluorocarbon nutrient emulsion (OFNE) perfusion system in the treatment of patients with severe hemispheric cerebral ischemia.Results: Four patients were enrolled in this pilot study. At admission, patients' National Institutes of Health Stroke Scale scores ranged from 16 to 24. The perfusion pathway was successfully established in all four patients. Maximum perfusion rates varied from 25 to 40 mL/minute; total volume perfused over the 24-hour period ranged from 30.6 to 45.8 L. ICP ranged from -3 to 16 mmHg during the perfusion. The 24-hour perfusion was successfully completed in all four patients with no serious adverse events during the perfusion.Conclusion: It is technically feasible and safe to establish a ventriculo-lumbar perfusion pathway using a specially designed lumbar drainage catheter and to control intracranial pressure while perfusing large volumes of OFNE. [ABSTRACT FROM AUTHOR]

Introduction: Neurointensivists are at the front line of treatment of patients who progress to death by neurological criteria (DNC). Although some of these patients will become organ donors, there has not been a systematic evaluation of the opinions and resources available to neurointensivists in regard to these important issues.Methods: We conducted a survey of neurointensivists regarding controversial issues in the declaration of DNC, procedures for discussing death and approaching donor families, and participation in donation after cardiac death (DCD).Results: The majority of centers described by the respondents had all five most commonly accepted ancillary tests to determine DNC (61%). Radionuclide blood flow studies are the most frequently reported test used (64%). Younger physicians are more likely to use trans-cranial Doppler exams (TCD) than their older counterparts (41% versus 28%, p<0.001). Discussions about DNC with the family are most often presided by the attending physician, and donation requests are most commonly initiated by organ procurement organization (OPO) representatives, but there is significant variation from center to center. Nine out of 10 physicians in our survey reported that they are likely to participate in DCD.Conclusion: Despite this enthusiasm, there is no clear consensus on many of the issues surrounding DCD, including how long after cardiac cessation recovery should begin. We believe that this study will serve as a springboard for more discussion about the diagnosis of DNC, the role of physicians in organ requests and donor management, and the procurement of organs through DCD. [ABSTRACT FROM AUTHOR]