Search

ObjectivePatients with acute lung or heart failure can experience hypoxic ischemic brain injury resulting in neurovascular unit (NVU) dysfunction. The NVU couples brain activity and perfusion. Extracorporeal membrane oxygenation (ECMO) is used for refractory lung and/or heart failure and often necessitates sedation, obfuscating neurological assessments. We hypothesized that combining cerebral electrographic activity and perfusion monitoring can detect brain injury in adults undergoing ECMO.MethodsFast Fourier transformation was used to identify fast (α+β) and slow (δ) power bands from cEEG. Diffuse correlation spectroscopy (DCS) measured blood flow index (BFI), a surrogate of perfusion, daily in adults undergoing ECMO. Correlations between α+β/δ ratio (ABDR) and BFI were compared between patients who were grouped into brain-injured and uninjured groups by neurologic exam and neuroimaging findings.ResultsTen patients (21-78 years old, five females, five brain-injured) underwent cEEG and DCS monitoring. Sixty-eight monitoring sessions (average 127 minutes/session) were analyzed. ABDR-BFI correlation was significantly higher in uninjured patients than brain-injured ones. Sedation did not significantly impact CBF-power band correlation.ConclusionsBrain-injured patients exhibited significantly less correlation between brain activity and perfusion, possibly as a result of NVU dysfunction.SignificanceABDR-BFI correlation can be measured continuously and noninvasively at the bedside and may represent a marker of NVU dysfunction.HighlightsQuantitative EEG and diffuse correlative spectroscopy can be used to measure markers of brain injury noninvasively, continuously, and at the bedside.Decreased ABDR-BFI correlation may be a marker of neurovascular decoupling in patients with hypoxic ischemic brain injury.ABDR-BFI correlation may be independent of analgosedation, which is used heavily in patients undergoing ECMO.

Effective treatment options for patients with life-threatening neurological disorders are limited. To address this unmet need, high-impact translational research is essential for the advancement and development of novel therapeutic approaches in neurocritical care. “The Neurotherapeutics Symposium 2019—Neurological Emergencies” conference, held in Rochester, New York, in June 2019, was designed to accelerate translation of neurocritical care research via transdisciplinary team science and diversity enhancement. Diversity excellence in the neuroscience workforce brings innovative and creative perspectives, and team science broadens the scientific approach by incorporating views from multiple stakeholders. Both are essential components needed to address complex scientific questions. Under represented minorities and women were involved in the organization of the conference and accounted for 30–40% of speakers, moderators, and attendees. Participants represented a diverse group of stakeholders committed to translational research. Topics discussed at the conference included acute ischemic and hemorrhagic strokes, neurogenic respiratory dysregulation, seizures and status epilepticus, brain telemetry, neuroprognostication, disorders of consciousness, and multimodal monitoring. In these proceedings, we summarize the topics covered at the conference and suggest the groundwork for future high-yield research in neurologic emergencies.

Objectives To perform a scoping literature review of cognitive, psychiatric, and quality of life outcomes in adults undergoing extracorporeal membrane oxygenation for any indication. Data sources We searched PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, and PsycINFO from inception to June 2019. Study selection Observational studies, clinical trials, qualitative studies, and case series with at least 10 adult subjects were included for analysis. Outcomes of interest consisted of general or domain-specific cognition, psychiatric illness, and quality of life measures that included both mental and physical health. Data extraction Study selection, data quality assessment, and interpretation of results were performed by two independent investigators in accordance with the PRISMA statement. Data synthesis Twenty-two articles were included in this review. Six described cognitive outcomes, 12 described psychiatric outcomes of which two were qualitative studies, and 16 described quality of life outcomes. Cognitive impairment was detected in varying degrees in every study that measured it. Three studies examined neuroimaging results and found neurologic injury to be more frequent in venoarterial versus venovenous extracorporeal membrane oxygenation, but described a variable correlation with cognitive impairment. Rates of depression, anxiety, and post-traumatic stress disorder were similar to other critically ill populations and were related to physical disability after extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation survivors' physical quality of life was worse than population norms but tended to improve with time, while mental quality of life did not differ significantly from the general population. Most studies did not include matched controls and instead compared outcomes to previously published values. Conclusions Extracorporeal membrane oxygenation survivors experience cognitive impairment, psychiatric morbidity, and worse quality of life compared with the general population and similar to other survivors of critical illness. Physical disability in extracorporeal membrane oxygenation patients plays a significant role in psychiatric morbidity. However, it remains unclear if structural brain injury plays a role in these outcomes and whether extracorporeal membrane oxygenation causes secondary brain injury.

Extracorporeal membrane oxygenation (ECMO) is a mechanical circulatory support method that is associated with a high burden of neurologic injury, but neurologic examination and imaging of this population presents prohibitive medical and logistical challenges. Diffuse correlation spectroscopy (DCS) can measure relative cerebral blood flow (rBF) non-invasively at the bedside. In this study we observed interhemispheric differences in rBF in response to mean arterial pressure (MAP) changes in adult ECMO recipients. Thirteen patients were recruited (ages 21-78, 7 with cardiac arrest, 4 with acute heart failure, 2 with acute respiratory distress syndrome). They were dichotomized via Glasgow Coma Scale Motor score (GCS-M) into comatose (GCS-M ≤ 4; n=4) and non-comatose (GCS-M > 4; n=9) groups. Comatose patients had more interhemispheric rBF asymmetry (ASYMrBF) vs. non-comatose patients over a range of MAP values (29% [IQR 23-34%] vs. 11% [IQR 8-13%], p=0.009). ASYMrBF in comatose patients resolved near a MAP range of 70-80 mm Hg, while rBF remained symmetric through a wider MAP range in non-comatose patients. Associations between post-oxygenator pCO2 or pH vs. ASYMrBF individually did not meet significance, though the linear model slopes were different between comatose and non-comatose subgroups. Here we have demonstrated asymmetric cerebral autoregulation in comatose ECMO patients.

Effects of extracorporeal membrane oxygenation (ECMO) treatment is a life saving treatment for patients that undergo cardiac or pulmonary arrest and is increasingly being used in adults. However, some adults develop brain injuries during treatment. Current neuroimaging techniques such as CT and MRI are inaccessible for these patients due to the high risk in moving them. In this study, we use diffuse correlation spectroscopy to non-invasively monitor cerebral blood flow in patients at the bedside during ECMO treatment. Using this data alongside physiological data, indices of cerebral autoregulation are calculated to observe how ECMO affects neurological health.

ObjectiveTo test the hypothesis that brain injury is more common and varied in patients receiving extracorporeal membrane oxygenation (ECMO) than radiographically observed, we described neuropathology findings of ECMO decedents and associated clinical factors from 3 institutions.MethodsWe conducted a retrospective multicenter observational study of brain autopsies from adult ECMO recipients. Pathology findings were examined for correlation with demographics, clinical data, ECMO characteristics, and outcomes.ResultsForty-three decedents (n = 13 female, median age 47 years) received autopsies after undergoing ECMO for acute respiratory distress syndrome (n = 14), cardiogenic shock (n = 14), and cardiac arrest (n = 15). Median duration of ECMO was 140 hours, most decedents (n = 40) received anticoagulants; 60% (n = 26) underwent venoarterial ECMO, and 40% (n = 17) underwent venovenous ECMO. Neuropathology was found in 35 decedents (81%), including microhemorrhages (37%), macrohemorrhages (35%), infarctions (47%), and hypoxic-ischemic brain injury (n = 17, 40%). Most pathology occurred in frontal neocortices (n = 43 occurrences), basal ganglia (n = 33), and cerebellum (n = 26). Decedents with hemorrhage were older (median age 57 vs 38 years, p = 0.01); those with hypoxic brain injury had higher Sequential Organ Failure Assessment scores (8.0 vs 2.0, p = 0.04); and those with infarction had lower peak Paco2 (53 vs 61 mm Hg, p = 0.04). Six of 9 patients with normal neuroimaging results were found to have pathology on autopsy. The majority underwent withdrawal of life-sustaining therapy (n = 32, 74%), and 2 of 8 patients with normal brain autopsy underwent withdrawal of life-sustaining therapy for suspected neurologic injury.ConclusionNeuropathological findings after ECMO are common, varied, and associated with various clinical factors. Further study on underlying mechanisms is warranted and may guide ECMO management.

Objective Mechanical ventilation (MV) has a complex interplay with the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH). We aim to provide a review of the physiology of MV in patients with aSAH, give recommendations based on a systematic review of the literature, and highlight areas that still need investigation. Data sources PubMed was queried for publications with the Medical Subject Headings (MeSH) terms “mechanical ventilation” and “aneurysmal subarachnoid hemorrhage” published between January 1, 1990, and March 1, 2020. Bibliographies of returned articles were reviewed for additional publications of interest. Study selection Study inclusion criteria included English language manuscripts with the study population being aSAH patients and the exposure being MV. Eligible studies included randomized controlled trials, observational trials, retrospective trials, case-control studies, case reports, or physiologic studies. Topics and articles excluded included review articles, pediatric populations, non-aneurysmal etiologies of subarachnoid hemorrhage, mycotic and traumatic subarachnoid hemorrhage, and articles regarding tracheostomies. Data extraction Articles were reviewed by one team member, and interpretation was verified by a second team member. Data synthesis Thirty-one articles met the inclusion criteria for this review. Conclusions We make recommendations on oxygenation, hypercapnia, PEEP, APRV, ARDS, and intracranial pressure monitoring.

Effects of extracorporeal membrane oxygenation (ECMO) treatment on brain health are currently unknown. For this study, we will noninvasively monitor these patients with diffuse correlation spectroscopy and transcranial doppler ultrasound during ECMO treatment.

Achieving and maintaining normothermia (NT) after subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) often require temperature modulating devices (TMD). Shivering is a common adverse effect of TMDs that can lead to further costs and complications. We evaluated an esophageal TMD, the EnsoETM (Attune Medical, Chicago, IL), to compare NT performance, shiver burden, and cost of shivering interventions with existing TMDs. Patients with SAH or ICH and refractory fever were treated with the EnsoETM. Patient demographics, temperature data, shiver severity, and amounts and costs of medications used for shiver management were prospectively collected. Controls who received other TMDs were matched for age, gender, and body surface area to EnsoETM recipients, and similar retrospective data were collected. All patients were mechanically ventilated. Fever burden was calculated as areas of curves of time spent above 37.5°C or 38°C. Demographics, temperature data, and costs of EnsoETM recipients were compared with recipients of other TMDs. Eight EnsoETM recipients and 24 controls between October 2015 and November 2016 were analyzed. There were no differences between the two groups in demographics or patient characteristics. No difference was found in temperature at initiation (38.7°C vs. 38.5°C, p = 0.4) and fever burden above 38°C (-0.44°C × hours vs. -0.53°C × hours, p = 0.47). EnsoETM recipients showed a nonsignificant trend in taking longer to achieve NT than other TMDs (5.4 hours vs. 2.9 hours, p = 0.07). EnsoETM recipients required fewer shiver interventions than controls (14 vs. 30, p = 0.02). EnsoETM recipients incurred fewer daily costs than controls ($124.27 vs. $232.76, p = 0.001). The EnsoETM achieved and maintained NT in SAH and ICH patients and was associated with less shivering and lower pharmaceutical costs than other TMDs. Further studies in larger populations are needed to determine the EnsoETM's efficacy in comparison to other TMDs.

Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary bypass that provides life-saving support to critically ill patients whose illness is progressing despite maximal conventional support. Use in adults is expanding, however neurological injuries are common. Currently, the existing brain imaging tools are a snapshot in time and require high-risk patient transport. Here we assess the feasibility of measuring diffuse correlation spectroscopy, transcranial Doppler ultrasound, electroencephalography, and auditory brainstem responses at the bedside, and developing a cerebral autoregulation metric. We report preliminary results from two patients, demonstrating feasibility and laying the foundation for future studies monitoring neurological health during ECMO.

Background: Regional cerebral oxygen saturation (rScO2) measured by near-infrared spectroscopy (NIRS) can be used to monitor brain oxygenation in extracorporeal membrane oxygenation (ECMO). ECMO patients that develop acute brain injuries (ABIs) are observed to have worse outcomes. We evaluated the association between rScO2 and ABI in venoarterial (VA) ECMO patients.Methods: We retrospectively reviewed prospectively-collected NIRS data from patients undergoing VA ECMO from April 2016 to October 2016. Baseline demographics, ECMO and clinical characteristics, cerebral oximetry data, neuroradiographic images, and functional outcomes were reviewed for each patient. rScO2 desaturations were defined as a >25% decline from baseline or an absolute value < 40% and quantified by frequency, duration, and area under the curve per hour of NIRS monitoring (AUC rate, rScO2*min/h). The primary outcome was ABI, defined as abnormalities noted on brain computerized tomography (CT) or magnetic resonance imaging (MRI) obtained during or after ECMO therapy.Results: Eighteen of Twenty patients who underwent NIRS monitoring while on VA ECMO were included in analysis. Eleven patients (61%) experienced rScO2 desaturations. Patients with desaturations were more frequently female (73 vs. 14%, p = 0.05), had acute liver dysfunction (64 vs. 14%, p = 0.05), and higher peak total bilirubin (5.2 mg/dL vs. 1.4 mg/dL, p = 0.02). Six (33%) patients exhibited ABI, and had lower pre-ECMO Glasgow Coma Scale (GCS) scores (5 vs. 10, p = 0.03) and higher peak total bilirubin levels (7.3 vs. 1.4, p = 0.009). All ABI patients experienced rScO2 desaturation while 42% of patients without ABI experienced desaturation (p = 0.04). ABI patients had higher AUC rates than non-ABI patients (right hemisphere: 5.7 vs. 0, p = 0.01, left hemisphere: 119 vs. 0, p = 0.06), more desaturation events (13 vs. 0, p = 0.05), longer desaturation duration (2:33 vs. 0, p = 0.002), and more severe desaturation events with rScO2 < 40 (9 vs. 0, p = 0.05). Patients with ABI had lower GCS scores (post-ECMO initiation) before care withdrawal or discharge than those without ABI (10 vs. 15, p = 0.02).Conclusions: The presence and burden of cerebral desaturations noted on NIRS cerebral oximetry are associated with secondary neurologic injury in adults undergoing VA ECMO.

Acute occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (tPA) and present an endovascular challenge. The aim of our study was to retrospectively delineate the feasibility of the combined use of emergent carotid stenting and intra-arterial (IA) Abciximab with intracranial revascularization in the setting of acute ischemic stroke and carotid occlusions at our institution.Eleven patients with complete cervical carotid occlusion with or without concomitant intracranial ICA and/or MCA occlusion were identified from a single center, retrospective review of patients admitted to the Stroke unit. We evaluated all cases for complications of emergent cervical ICA recanalization employing carotid stenting and IA Abciximab.All patients had complete cervical carotid occlusion with (n = 8) or without (n = 3) concomitant intracranial ICA and/or MCA occlusion. Successful emergent cervical ICA recanalization was achieved in all cases. All patients were administered IA Abciximab (dose range 6-17 mg, average 11.4 mg) immediately following the cervical carotid stenting. There was complete recanalization in all patients with no procedural morbidity or mortality. A single case (1/11, 9%) developed asymptomatic hemorrhagic transformation. Upon discharge, 9 patients (9/11, 82%) had a mRS of 0-2 and 2 patients (2/11, 18%) had a mRS of 3.In acute ICA-MCA/distal ICA occlusions, extracranial stenting followed by intracranial IA Abciximab and thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.

Acute neurological injuries result in activation of sympathetic and inflammatory pathways that have significant impact on the resting metabolic rate. The resultant hypermetabolic state, if not fully supported, can result in a malnourished state, influence secondary complications, and impair the recovery process. Therefore, it is important to recognize the nutritional status of patients in the neurocritical care setting. Unfortunately, much of the data supporting nutritional support is derived from studies in a general critical care population and does not address specific needs for the neurologically injured patient population. This chapter will provide an updated review of the literature on methods by which to monitor and manage nutritional status for common diseases in the neurocritical care setting. Additionally, new concepts of providing nutritional interventions as targeted therapies modulating the immune response after neurological injury will be discussed.