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Neurocritical Care: New Insights and Challenges
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Neurocritical Care: New Insights and Challenges

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: closed (20 October 2024) | Viewed by 10182

Special Issue Editors

Dr. Konstantinos Dimitriadis

E-Mail Website
Guest Editor
Department of Neurology, University Hospital LMU Munich, 81377 Munich, Germany
Interests: neurointensive care medicine; postoperative delirium
Prof. Dr. Julian Bösel

E-Mail Website
Guest Editor
Department of Neurology, University Hospital Heidelberg, 69120 Heidelberg, Germany
Interests: acute brain injury; acute ischemic stroke; intracranial hemorrhage

Special Issue Information

Dear Colleagues,

In recent years, specialized neurocritical care with early recognition and prevention of secondary brain injury has resulted in superior patient outcomes. Although the overall low number of patients per unit and ethical considerations regarding RCTs make meaningful research difficult, the community has generated a substantial body of evidence for the treatment strategies in neurointensive care units in recent decades.

Given the multidisciplinary and multiprofessional teams and the data- and resource-intensive environments, management aspects, including health care policy, as well as strategies applying advanced technology, may play an important role. Furthermore, biomarkers to allow personalized treatment and insights into the management of complications and of neurocritical care are warranted.

This Special Issue provides insights into novel advances and challenges in neurocritical care with an emphasis on monitoring, treatment strategies, prognosis and cost-effectiveness.

Dr. Konstantinos Dimitriadis
Prof. Dr. Julian Bösel
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • neurocritical care
  • acute brain injury
  • monitoring
  • treatment
  • cost-effectiveness

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Published Papers (7 papers)

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Research

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15 pages, 6239 KiB  
Article
The Role of Transcranial Ultrasound Imaging in Intensive Care Treatment of Decompressive Hemicraniectomy Patients: A Retrospective Single-Center Analysis
by Martin Petkov, Ralf Becker, Max Schneider, Michal Hlavac, Andreas Knoll, Christian Rainer Wirtz, Ralph König and Andrej Pala
J. Clin. Med. 2024, 13(24), 7704; https://doi.org/10.3390/jcm13247704 - 17 Dec 2024
Viewed by 766
Abstract
Background: Post-hemicraniectomy patients often need extended intensive care treatment. While computed tomography (CT) is considered the gold standard for regular imaging, its frequent use could be linked to adverse clinical outcomes. This study aimed to assess bedside transcranial ultrasound (TUS) to capture [...] Read more.
Background: Post-hemicraniectomy patients often need extended intensive care treatment. While computed tomography (CT) is considered the gold standard for regular imaging, its frequent use could be linked to adverse clinical outcomes. This study aimed to assess bedside transcranial ultrasound (TUS) to capture intracranial anatomical structures and pathologies. Methods: We analyzed 19 patients treated in our neurosurgical ICU from 1 January 2023 to 1 February 2024. Six physicians from our unit (three residents and three attending physicians) conducted a retrospective evaluation. A total of 158 sessions, including multiple freeze frames and video footage, were analyzed, including 7 imaging categories, using a Likert scale. Subsequently, correlation between CT and TUS was evaluated for midline (ML) shift, subdural space, lateral ventricular width (LVW), and extent of intracerebral hematoma using the Pearson’s correlation coefficient (r). Results: TUS was performed on average on 8.32/19.53 days (mean inpatient stay). It provided the lowest Likert scores for the imaging categories ventricular system, midline, subdural space, intraventricular catheter placement, and cortical gyration. Residents reported slightly inferior assessability, resulting in higher scores on the Likert scale (0.02–0.93 mean difference compared with attending physicians). A high correlation was shown in terms of ML shift, LVW, and intracerebral hematomas. No relevant correlation was shown in subdural space. Conclusions: TUS is a safe, cost-, and time-efficient method, potentially gaining relevance for imaging post-hemicraniectomy patients. In our setting, the method seemed effective in depicting intraventricular catheter placement, hydrocephalus, ML shift, and space-occupying lesions. Further improvement in image quality could potentially reduce the overall number of indicated CT scans. Full article
(This article belongs to the Special Issue Neurocritical Care: New Insights and Challenges)
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12 pages, 1105 KiB  
Article
Results of an Online Survey on Intensive Care Management of Patients with Aneurysmal Subarachnoid Hemorrhage in German-Speaking Countries
by Anisa Myftiu, Lisa Mäder, Ilia Aroyo, Rainer Kollmar and on behalf of the IGNITE Study Group & DIVI Section Studies & Standards
J. Clin. Med. 2024, 13(24), 7614; https://doi.org/10.3390/jcm13247614 - 13 Dec 2024
Viewed by 839
Abstract
Background: The clinical course of patients with aneurysmal SAH (aSAH) is often dynamic and highly unpredictable. Since its management varies between hospitals despite guidelines, this survey aimed to assess the current state of intensive care treatment for aSAH in the German-speaking region and [...] Read more.
Background: The clinical course of patients with aneurysmal SAH (aSAH) is often dynamic and highly unpredictable. Since its management varies between hospitals despite guidelines, this survey aimed to assess the current state of intensive care treatment for aSAH in the German-speaking region and provide insights that could aid standardization of care for aSAH patients in the intensive care setting. Methods: From February 2023 to April 2023, medical professionals of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), the Initiative of German Neuro-Intensive Trial Engagement (IGNITE) network and manually recorded clinics with intensive care units were invited to participate in a standardized anonymous online questionnaire including 44 questions. The questionnaire was validated in multiple steps by experts of different specialties including those from the DIVI. A descriptive data analysis was carried out. Results: A total of 135 out of 220 participants answered the survey completely. The results showed that most patients were treated in anesthesia-led intensive care units at university and maximum care hospitals. Aneurysms were usually treated within 24 h after bleeding. If vasospasm was detected, induced hypertension was usually implemented as the first treatment option. In refractory vasospasm, interventional spasmolysis with calcium antagonists was usually carried out (81%), despite unclear evidence. There were significant discrepancies in blood pressure target values, particularly after aneurysm repair or after delayed cerebral ischemia (DCI), as well as in hemoglobin limit values for erythrocyte substitution. Despite the limited level of evidence, most institutions used temperature management (68%), including hypothermia (56%), for severe cases. Conclusions: While we anticipated variations between individual intensive care facilities, our survey identified numerous similarities in the treatment of aSAH patients. Methods such as interventional spasmolysis and temperature management were used frequently despite limited evidence. Our results can serve as a fundamental framework for formulating recommendations for intensive care treatment and planning of multicenter studies. Full article
(This article belongs to the Special Issue Neurocritical Care: New Insights and Challenges)
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12 pages, 774 KiB  
Article
Routine ICU Surveillance after Brain Tumor Surgery: Patient Selection Using Machine Learning
by Jan-Oliver Neumann, Stephanie Schmidt, Amin Nohman, Paul Naser, Martin Jakobs and Andreas Unterberg
J. Clin. Med. 2024, 13(19), 5747; https://doi.org/10.3390/jcm13195747 - 26 Sep 2024
Cited by 1 | Viewed by 1005
Abstract
Background/Objectives: Routine postoperative ICU admission following brain tumor surgery may not benefit selected patients. The objective of this study was to develop a risk prediction instrument for early (within 24 h) postoperative adverse events using machine learning techniques. Methods: Retrospective cohort of 1000 [...] Read more.
Background/Objectives: Routine postoperative ICU admission following brain tumor surgery may not benefit selected patients. The objective of this study was to develop a risk prediction instrument for early (within 24 h) postoperative adverse events using machine learning techniques. Methods: Retrospective cohort of 1000 consecutive adult patients undergoing elective brain tumor resection. Nine events/interventions (CPR, reintubation, return to OR, mechanical ventilation, vasopressors, impaired consciousness, intracranial hypertension, swallowing disorders, and death) were chosen as target variables. Potential prognostic features (n = 27) from five categories were chosen and a gradient boosting algorithm (XGBoost) was trained and cross-validated in a 5 × 5 fashion. Prognostic performance, potential clinical impact, and relative feature importance were analyzed. Results: Adverse events requiring ICU intervention occurred in 9.2% of cases. Other events not requiring ICU treatment were more frequent (35% of cases). The boosted decision trees yielded a cross-validated ROC-AUC of 0.81 ± 0.02 (mean ± CI95) when using pre- and post-op data. Using only pre-op data (scheduling decisions), ROC-AUC was 0.76 ± 0.02. PR-AUC was 0.38 ± 0.04 and 0.27 ± 0.03 for pre- and post-op data, respectively, compared to a baseline value (random classifier) of 0.092. Targeting a NPV of at least 95% would require ICU admission in just 15% (pre- and post-op data) or 30% (only pre-op data) of cases when using the prediction algorithm. Conclusions: Adoption of a risk prediction instrument based on boosted trees can support decision-makers to optimize ICU resource utilization while maintaining adequate patient safety. This may lead to a relevant reduction in ICU admissions for surveillance purposes. Full article
(This article belongs to the Special Issue Neurocritical Care: New Insights and Challenges)
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9 pages, 513 KiB  
Article
No Harmful Effect of Endovascular Treatment before Decompressive Surgery—Implications for Handling Patients with Space-Occupying Brain Infarction
by Johann Otto Pelz, Simone Engelmann, Cordula Scherlach, Peggy Bungert-Kahl, Alhuda Dabbagh, Dirk Lindner and Dominik Michalski
J. Clin. Med. 2024, 13(3), 918; https://doi.org/10.3390/jcm13030918 - 5 Feb 2024
Cited by 1 | Viewed by 1246
Abstract
This study explored short- and mid-term functional outcomes in patients undergoing decompressive hemicraniectomy (DHC) due to space-occupying cerebral infarction and asked whether there is a potentially harmful effect of a priorly performed endovascular treatment (EVT). Medical records were screened for patients requiring DHC [...] Read more.
This study explored short- and mid-term functional outcomes in patients undergoing decompressive hemicraniectomy (DHC) due to space-occupying cerebral infarction and asked whether there is a potentially harmful effect of a priorly performed endovascular treatment (EVT). Medical records were screened for patients requiring DHC due to space-occupying cerebral infarction between January 2016 and July 2021. Functional outcomes at hospital discharge and at 3 months were assessed by the modified Rankin Scale (mRS). Out of 65 patients with DHC, 39 underwent EVT before DHC. Both groups, i.e., EVT + DHC and DHC alone, had similar volumes (280 ± 90 mL vs. 269 ± 73 mL, t-test, p = 0.633) and proportions of edema and infarction (22.1 ± 6.5% vs. 22.1 ± 6.1%, t-test, p = 0.989) before the surgical intervention. Patients undergoing EVT + DHC tended to have a better functional outcome at hospital discharge compared to DHC alone (mRS 4.8 ± 0.8 vs. 5.2 ± 0.7, Mann–Whitney-U, p = 0.061), while the functional outcome after 3 months was similar (mRS 4.6 ± 1.1 vs. 4.8 ± 0.9, Mann–Whitney-U, p = 0.352). In patients initially presenting with a relevant infarct demarcation (Alberta Stroke Program Early CT Score ≤ 5), the outcome was similar at hospital discharge and after 3 months between patients with EVT + DHC and DHC alone. This study provided no evidence for a harmful effect of EVT before DHC in patients with space-occupying brain infarction. Full article
(This article belongs to the Special Issue Neurocritical Care: New Insights and Challenges)
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14 pages, 797 KiB  
Article
Intrahospital Transport of Critically Ill Patients with Subarachnoid Hemorrhage—Frequency, Timing, Complications, and Clinical Consequences
by Moritz L. Schmidbauer, Tim L. T. Wiegand, Linus Keidel, Julia Zibold and Konstantinos Dimitriadis
J. Clin. Med. 2023, 12(24), 7666; https://doi.org/10.3390/jcm12247666 - 13 Dec 2023
Cited by 1 | Viewed by 1665
Abstract
Background: Patients with subarachnoid hemorrhage (SAH) often necessitate intra-hospital transport (IHT) during intensive care treatment. These transfers to facilities outside of the neurointensive care unit (NICU) pose challenges due to the inherent instability of the hemodynamic, respiratory, and neurological parameters that are typical [...] Read more.
Background: Patients with subarachnoid hemorrhage (SAH) often necessitate intra-hospital transport (IHT) during intensive care treatment. These transfers to facilities outside of the neurointensive care unit (NICU) pose challenges due to the inherent instability of the hemodynamic, respiratory, and neurological parameters that are typical in these patients. Methods: In this retrospective, single-center cohort study, a total of 108 IHTs were analyzed for demographics, transport rationale, clinical outcomes, and pre/post-IHT monitoring parameters. After establishing clinical thresholds, the frequency of complications was calculated, and predictors of thresholds violations were determined. Results: The mean age was 55.7 (+/−15.3) years, with 68.0% showing severe SAH (World Federation of Neurosurgical Societies Scale 5). IHTs with an emergency indication made up 30.8% of all transports. Direct therapeutic consequences from IHT were observed in 38.5%. On average, the first IHT occurred 1.5 (+/−2.0) days post-admission and patients were transported 4.3 (+/−1.8) times during their stay in the NICU. Significant parameter changes from pre- to post-IHT included mean arterial pressure, systolic blood pressure, oxygen saturation, blood glucose levels, temperature, dosages of propofol and ketamine, tidal volume, inspired oxygen concentration, Horovitz index, glucose, pH, intracranial pressure, and cerebral perfusion pressure. Relevant hemodynamic thresholds were violated in 31.5% of cases, while respiratory complications occurred in 63.9%, and neurological complications in 20.4%. For hemodynamic complications, a low heart rate with a threshold of 61/min (OR 0.96, 95% CI 0.93–0.99, p = 0.0165) and low doses of midazolam with a threshold of 17.5 mg/h (OR 0.97, 95% CI 0.95–1.00, p = 0.0232) significantly predicted adverse events. However, the model did not identify significant predictors for respiratory and neurological outcomes. Conclusions: Conclusively, IHTs in SAH patients are associated with relevant changes in hemodynamic, respiratory, and neurological monitoring parameters, with direct therapeutic consequences in 4/10 IHTs. These findings underscore the importance of further studies on the clinical impact of IHTs. Full article
(This article belongs to the Special Issue Neurocritical Care: New Insights and Challenges)
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11 pages, 1040 KiB  
Article
Usage of Inhalative Sedative for Sedation and Treatment of Patient with Severe Brain Injury in Germany, a Nationwide Survey
by Svea Roxana Roggenbuck, André Worm, Martin Juenemann, Christian Claudi, Omar Alhaj Omar, Marlene Tschernatsch, Hagen B. Huttner and Patrick Schramm
J. Clin. Med. 2023, 12(19), 6401; https://doi.org/10.3390/jcm12196401 - 8 Oct 2023
Cited by 4 | Viewed by 1585
Abstract
Brain injured patients often need deep sedation to prevent or treat increased intracranial pressure. The mainly used IV sedatives have side effects and/or high context-sensitive half-lives, limiting their use. Inhalative sedatives have comparatively minor side effects and a brief context-sensitive half-life. Despite the [...] Read more.
Brain injured patients often need deep sedation to prevent or treat increased intracranial pressure. The mainly used IV sedatives have side effects and/or high context-sensitive half-lives, limiting their use. Inhalative sedatives have comparatively minor side effects and a brief context-sensitive half-life. Despite the theoretical advantages, evidence in this patient group is lacking. A Germany-wide survey with 21 questions was conducted to find out how widespread the use of inhaled sedation is. An invitation for the survey was sent to 226 leaders of intensive care units (ICU) treating patients with brain injury as listed by the German Society for Neurointensive Care. Eighty-nine participants answered the questionnaire, but not all items were responded to, which resulted in different absolute counts. Most of them (88%) were university or high-level hospital ICU leaders and (67%) were leaders of specialized neuro-ICUs. Of these, 53/81 (65%) use inhalative sedation, and of the remaining 28, 17 reported interest in using this kind of sedation. Isoflurane is used by 43/53 (81%), sevoflurane by 15/53 (28%), and desflurane by 2. Hypotension and mydriasis are the most common reported side effects (25%). The presented survey showed that inhalative sedatives were used in a significant number of intensive care units in Germany to treat severely brain-injured patients. Full article
(This article belongs to the Special Issue Neurocritical Care: New Insights and Challenges)
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Review

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16 pages, 1286 KiB  
Review
Resuscitation and Initial Management After Moderate-to-Severe Traumatic Brain Injury: Questions for the On-Call Shift
by Jesús Abelardo Barea-Mendoza, Mario Chico-Fernández, Maria Angeles Ballesteros, Alejandro Caballo Manuel, Ana M. Castaño-Leon, J. J. Egea-Guerrero, Alfonso Lagares, Guillermo Morales-Varas, Jon Pérez-Bárcena, Luis Serviá Goixart and Juan Antonio Llompart-Pou
J. Clin. Med. 2024, 13(23), 7325; https://doi.org/10.3390/jcm13237325 - 2 Dec 2024
Viewed by 2093
Abstract
Traumatic brain injury (TBI) is a leading cause of disability and mortality globally, stemming from both primary mechanical injuries and subsequent secondary responses. Effective early management of moderate-to-severe TBI is essential to prevent secondary damage and improve patient outcomes. This review provides a [...] Read more.
Traumatic brain injury (TBI) is a leading cause of disability and mortality globally, stemming from both primary mechanical injuries and subsequent secondary responses. Effective early management of moderate-to-severe TBI is essential to prevent secondary damage and improve patient outcomes. This review provides a comprehensive guide for the resuscitation and stabilization of TBI patients, combining clinical experience with current evidence-based guidelines. Key areas addressed in this study include the identification and classification of severe TBI, intubation strategies, and optimized resuscitation targets to maintain cerebral perfusion. The management of coagulopathy and special considerations for patients with concomitant hemorrhagic shock are discussed in depth, along with recommendations for neurosurgical interventions. This article further explores the role of multimodal neuromonitoring and targeted temperature management to mitigate secondary brain injury. Finally, it discusses end-of-life care in cases of devastating brain injury (DBI). This practical review integrates foundational and recent advances in TBI management to aid in reducing secondary injuries and enhancing long-term recovery, presenting a multidisciplinary approach to support acute care decisions in TBI patients. Full article
(This article belongs to the Special Issue Neurocritical Care: New Insights and Challenges)
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