Acute spontaneous intracerebral hemorrhage and traumatic brain injury are the most common causes of critical illness in the ICU and have high early mortality.

BACKGROUND: Critical care covers multiple disciplines. However, the causes of critical illness in the ICU, particularly the most common causes, remain unclear. We aimed to investigate the incidence and the most common causes of critical illness and the corresponding early mortality rates in ICU patients. METHODS: A retrospective cohort study was performed to examine critically ill patients (aged over 15 years) in the general ICU in Shuyang County in northern China (1/2014-12/2015). The incidences and causes of critical illnesses and their corresponding early mortality rates in the ICU were determined by an expert panel. RESULTS: During the 2-year study period, 1,211,138 person-years (PY) and 1645 critically ill patients (mean age, 61.8 years) were documented. The median Glasgow Coma Scale (GCS) score was 6 (range, 3-15). The mean acute physiology and chronic health evaluation II (APACHE II) score was 21.2 ± 6.8. The median length of the ICU stay was 4 days (range, 1-29 days). The most common causes of critical illness in the ICU were spontaneous intracerebral hemorrhage (SICH) (26%, 17.6/100,000 PY) and traumatic brain injury (TBI) (16.8%, 11.4/100,000 PY). During the first 7 days in the ICU, SICH was the most common cause of death (42.2%, 7.4/10,000 PY), followed by TBI (36.6%, 4.2/100,000 PY). Based on a logistic analysis, older patients had a significantly higher risk of death from TBI (risk ratio [RR], 1.7; 95% CI, 1.034-2.635), heart failure/cardiovascular crisis (RR, 0.2; 95% CI, 0.083-0.484), cerebral infarction (RR, 0.15; 95% CI, 0.050-0.486), or respiratory failure (RR, 0.35; 95% CI, 0.185-0.784) than younger patients. However, the risk of death from SICH in the two groups was similar. CONCLUSIONS: The most common causes of critical illness in the ICU were SICH and TBI, and both critical illnesses showed a higher risk of death during the first 7 days in the ICU.

No Awakening in Supratentorial Intracerebral Hemorrhage Is Potentially Caused by Sepsis-Associated Encephalopathy.

BACKGROUND Acute supratentorial intracerebral hemorrhage (sICH) with secondary sepsis is increasing in frequency. We investigated whether no awakening (NA) after sICH with coma is potentially caused by sepsis-associated encephalopathy (SAE). MATERIAL AND METHODS A case-control study of 147 recruited sICH cases with NA and 198 sICH controls with subsequent awakening (SA) was performed at 2 centers in China. All patients underwent brain computed tomography (CT) scans on admission. The odds ratio (OR) of NA was calculated using logistic regression. RESULTS During the study period, 56.5% (83/147) of the patients with sICH with coma and NA had SAE, and 10% (20/198) with sICH with coma and SA had SAE; this difference between the 2 groups was significant (p<0.000). The sICH patients with coma and NA exhibited a longer median time from onset to coma (2.0 days vs. 0.5 days), more frequent confirmed infection (98.0% vs. 24.2%), and a higher Sequential Organ Failure Assessment (SOFA) score (6.3±1.5 vs. 3.4±0.8). These patients also exhibited lower hematoma volume (28.0±18.8 vs. 38.3±24), a lower initial National Institutes of Health Stroke Scale score (19.5±6.6 vs. 30.3±6.8), more frequent brain midline shift (59.2% vs. 27.8%), more frequent diffuse cerebral swelling (64.6% vs. 16.0%), and higher 30-day mortality (54.4% vs. 0.0%) than the patients who did awaken. Logistic multivariable regression analyses revealed that only a higher SOFA score (OR, 1.4; 95% CI, 1.079-1.767; p=0.010) and SAE (OR, 4.0; 95% CI, 1.359-6.775; p=0.001) were associated with NA events in patients with sICH. CONCLUSIONS NA in sICH patients with coma is potentially caused by secondary SAE.

[Comparison of risk of death between older and non-older critical patients in ICU: a retrospective cohort study of consecutive 3 years].

OBJECTIVE: To investigate the risk of death between older and non-older critical patients in intensive care unit (ICU) in Shuyang People's Hospital. METHODS: A retrospective cohort study was conducted. The critical patients who aged 15 or above, and admitted to ICU of Shuyang People's Hospital from January 2014 to December 2016 were enrolled, and all the data was collected from the registration and electronic medical records in the ICU. The prevalence and causes of death in ICU critical patients during the study period were observed. The patients were divided into elderly group (65 years and older) and non-elderly group (15-65 years), and logistic regression analysis was performed for the risk of death in the two groups. RESULTS: During the study period, 2 707 critical patients in emergency were admitted to the ICU of Shuyang People's Hospital, and patients not satisfied the inclusion criteria were excluded. Finally, a total of 2 466 patients were enrolled in the analysis with the male and female ratio of 1.6 : 1, an average age of (61.8±17.3) years, a median Glasgow coma scale (GCS) score of 6 (4, 8), and with a median ICU stay of 3 (1, 6) days. In 2 466 critical patients, the most common cause of critical state was spontaneous intracerebral hemorrhage (25.5%) and traumatic brain injury (17.0%), with a fatality rate of 46.0% and 39.5% within first 7 days respectively. Compared with the non-elderly patients (n = 1 415), the incidences of death of the elderly patients (n = 1 051) due to traumatic brain injury, cerebral infarction, heart failure/cardiovascular crisis, and respiratory critically ill were significantly increased (9.4% vs. 4.7%, 2.9% vs. 0.8%, 5.0% vs. 2.1%, 2.5% vs. 1.0%, respectively), while the incidence of death for pesticide/drug poisoning in the elderly group was significantly lower than that in the non-elderly group (0.2% vs. 1.2%, all P < 0.01). Stepwise logistic regression analysis showed that traumatic brain injury [hazard ratio (HR) = 1.878, 95% confidence interval (95%CI) = 1.233-2.864, P = 0.003), cerebral infarction (HR = 0.435, 95%CI = 0.229-0.826, P = 0.011), heart failure/cardiovascular crisis (HR = 0.399, 95%CI = 0.238-0.668, P = 0.000), and respiratory critically ill (HR = 0.239, 95%CI = 0.126-0.453, P = 0.000) in the older patients were significantly high risk factors of death as compared with those in non-older patients. CONCLUSIONS: In the general ICU, the most common cause is spontaneous intracerebral hemorrhage and traumatic brain injury in critical patients with a high fatality rate. The risk of death in elderly patients with severe traumatic brain injury, cerebral infarction, heart failure/cardiovascular crisis, respiratory critically ill is higher than that of the non-elderly patients.

Risk factors for nosocomial nontraumatic coma: sepsis and respiratory failure.

BACKGROUND: Coma's are a major cause of clinical deterioration or death. Identification of risks that predispose to coma are important in managing patients; however, the risk factors for nosocomial nontraumatic coma (NNC) are not well known. Our aim was to investigate the risk factors in patients with NNC. METHODS: A retrospective case-control design was used to compare patients with NNC and a control group of patients without coma in a population-based cohort of 263 participants from the neurological intensive care unit in Shuyang County People's Hospital of Northern China. Coma was diagnosed by a Glasgow Coma Scale score ≤8. Adjusted odds ratios for patients with NNC were derived from multivariate logistic regression analyses. RESULTS: A total of 96 subjects had NNC. The prevalence of NNC was 36.5% among the subjects. Among these, 82% had acute cerebrovascular etiology. Most of the NNC usually occurred at day 3 after admission to the neurological intensive care unit. Patients with NNC had higher hospital mortality rates (67.7% vs 3%, P<0.0001) and were more likely to have a central herniation (47.9% vs 0%, P<0.001) or uncal herniation (11.5% vs 0%, P<0.001) than those without NNC. Multiple logistic regression showed that systemic inflammatory response syndrome-positive sepsis (odds ratio =4, 95% confidence interval =1.875-8.567, P<0.001) and acute respiratory failure (odds ratio =3.275, 95% confidence interval =1.014-10.573, P<0.05) were the factors independently associated with a higher risk of NNC. CONCLUSION: Systemic inflammatory response syndrome-positive sepsis and acute respiratory failure are independently associated with an increased risk of NNC. This information may be important for patients with NNC.

Metabolic Syndrome Is a Strong Risk Factor for Minor Ischemic Stroke and Subsequent Vascular Events.

BACKGROUND: Minor ischemic stroke (MIS) represents a major global public health problem worldwide due to high incidence. The aim of this study was to investigate whether metabolic syndrome (MetS) is a strong risk for MIS and subsequent vascular events (SVE). METHODS: A retrospective cohort study was performed examining symptomatic MIS in a Chinese neurologic outpatient population aged over 25 years without history of stroke. MetS was defined using the International Diabetes Federation criteria. MIS was diagnosed by magnetic resonance imaging-diffusion weighted images or fluid-attenuated inversion recovery. RESULTS: Of 1361 outpatients, a total of 753 (55.3%) patients were diagnosed with MIS; of them, 80% had a score of 0 using the MIS had a 0 score on the National Institutes of Health Stroke Scale. Among these, 303 (40.2%) individuals with MIS were diagnosed with MetS. Diagnosed of MIS with MetS significantly correlated with abdominal obesity (30.7% v.s 18.0%), hypertension (91.1% v.s 81.6%), increased blood glucose (6.9±2.4 v.s 5.0±0.4), dyslipidemia (78.2% v.s 48.2%), and SVE (50.5% v.s 11.3%) when compared with the controls group. On adjusted analysis, the risk of SVE was also significantly associated with three additional MetS criterion (RR,9.0; 95% CI, 5.677-14.46). Using Cox proportional analysis, risk of SVE in patient with MIS was significantly associated with MetS (RR, 3.3; 95% CI, 1.799-6.210), older age (RR, 1.0; 95% CI, 1.001-1.048), and high blood glucose (RR,1.1; 95%CI, 1.007-1.187). CONCLUSIONS: The MetS is a strong risk factor for MIS, and patients presenting with MIS and MetS are at a high risk of SVE. Further studies are required to determine the improvement of Mets prevention in the reduction of MIS and SVE.

[Sepsis associated encephalopathy is an independently risk factor for nosocomial coma in patients with supratentorial intracerebral hemorrhage: a retrospective cohort study of 261 patients].

OBJECTIVE: To investigate whether the presence of sepsis associated encephalopathy (SAE) would predict nosocomial coma (NC) and poor outcome in patients with supratentorial intracerebral hemorrhage (SICH). METHODS: A retrospective cohort study was conducted. The adult acute SICH patients with or without coma admitted to intensive care unit (ICU) of Shuyang People' Hospital Affiliated to Xuzhou Medical University from December 2012 to December 2015 were enrolled. Brain computed tomography (CT) scans were analyzed and the patients were divided into pre-hospital coma (PC) and NC groups. The clinical data and the incidence of SAE of patients in two groups were compared, and the 30-day prognosis was followed up. Univariate and Cox regression analyses were performed to analyze whether SAE would predict NC and poor outcome in patients with SICH. RESULTS: A total of 330 patients with acute SICH and coma were enrolled, excluding 60 cases of infratentorial cerebral hemorrhage, 3 cases of primary intraventricular hemorrhage, and 6 cases of unknown volume hematoma. Finally, 261 patients were included, with 111 patients of NC events, and 150 patients of PC events. 69 (62.2%) SAE in SICH with NC and 33 (22.2%) SAE in SICH with PC was diagnosed, and the incidence of SAE between two groups was statistically significant (P < 0.01). Compared with PC group, SICH patients in the NC group had lower incidence of hypertension (81.1% vs. 96.0%), longer time from onset to NC [days: 2.3 (23.9) vs. 0 (0.5)] and length of ICU stay [days: 5.0 (34.0) vs. 3.0 (12.0)], higher initial Glasgow coma score (GCS, 10.2±1.5 vs. 6.6±1.6) and sequential organ failure assessment (SOFA) score [4.0 (6.0) vs. 3.0 (3.0)], lower initial National Institutes of Health Stroke Scale (NIHSS) score (19.4±6.6 vs. 30.2±6.8), as well as more frequent sepsis (78.4% vs. 38.0%), vegetative state (24.3% vs. 14.0%), acute respiratory failure (24.3% vs. 10.0%), pneumonia (37.8% vs. 24.0%), septic shock (8.1% vs. 0), acute liver failure (5.4% vs. 0), hypernatremia (8.1% vs. 0), CT indicating that more frequent vasogenic edema (64.9% vs. 16.0%) and white matter lesion (13.5% vs. 2.0%), and less mannitol usage (94.6% vs. 100.0%), and less brain midline shift (32.4% vs. 68.0%) and hematoma enlargement (8.1% vs. 30.0%), less hematoma volume (mL: 28.0±18.8 vs. 38.3±24.4) in CT, and higher 30-day mortality (54.1% vs. 26.0%) with statistical differences (all P < 0.05). It was shown by Cox regression analyses that SAE [hazard ratio (HR) = 3.5, 95% confidence interval (95%CI) = 1.346-6.765, P = 0.000] and SOFA score (HR = 1.8, 95%CI = 1.073-1.756, P = 0.008) were independent risk factors of death of SICH patients with NC, and hematoma enlargement was independent risk factor of death of SICH patients with PC (HR = 3.0, 95%CI = 1.313-5.814, P = 0.000). CONCLUSIONS: SAE is the independent factor of inducing NC event and poor prognosis in SICH patients.

Transient and persistent symptoms in patients with lacunar infarction: results from a prospective cohort study.

BACKGROUND: The transient symptoms with lacunar infarction (TSI) and persistent symptoms with lacunar infarction (PSI) are the most common forms of symptomatic lacunar infarction (LI). The aim of this study was to compare the differences in TSI and PSI of symptomatic LI. METHODS: A prospective cohort study was conducted in the neurologic outpatients of the tertiary teaching hospital in Northern China between February 2011 and February 2012. The TSI and PSI in participants aged 35 years or over were assessed. Patients were followed up and their outcomes were compared. RESULTS: Of the 453 symptomatic outpatients, 251 patients with LI were diagnosed by magnetic resonance imaging. Approximately 77.3% (194/251) of the patients with LI at this time had TSI. and the remaining 23.7% had PSI. After the adjusted odds ratios, only middle age (risk ratio [RR], 1.1; 95% confidence interval [CI], 1.157-1.189), lower National Institutes of Health Stroke Scale score (RR, 20.6; 95% CI, 6.705-13.31), smaller lacunae on brain images (RR, 2.9; 95% CI, 1.960-4.245), and LI frequently in the anterior circulation territory (RR, 0.2; 95% CI, 0.079-0.721) were independently associated with TSI. During a mean follow-up of 6 months, survival rate was significantly higher among patients with TSI than among those with PSI (log rank, 6.9; P=0.010); estimated unadjusted incidence of vascular subsequent events (30.9% vs 54.4%, P=0.001) was significantly lower in TSI than in PSI. CONCLUSION: The TSI has a higher prevalence and is associated with a lower risk of vascular subsequent events and death than PSI. The implications of these findings for TSI and PSI may require different interventions.

Early prediction and outcome of septic encephalopathy in acute stroke patients with nosocomial coma.

BACKGROUND: Septic encephalopathy (SE) is the most common acute encephalopathy in ICU; however, little attention has been focused on risk of SE in the course of acute stroke. Our aim is to investigate the early prediction and outcome of SE in stroke patients with nosocomial coma (NC). METHODS: A retrospective cohort study was conducted in an ICU of the tertiary teaching hospital in China from January 2006 to December 2009. Ninety-four acute stroke patients with NC were grouped according to with or without SE. Risk factors for patients with SE were compared with those without SE by univariate and multivariate analysis. RESULTS: Of 94 stroke patients with NC, 46 (49%) had NC with SE and 48 (51%) had NC without SE. The onset-to-NC time was significant later in stroke patients with SE than those without SE (P < 0.01). There was a significant difference in body temperature, heart rate, respiratory rate, white blood cell (WBC), systolic blood pressure (SBP), diastolic blood pressure (DBP), systemic inflammatory response syndrome (SIRS), acute respiratory failure, septic shock, hypernatremia, and sequential organ failure assessment (SOFA) score between the SE and non-SE group (P < 0.05). On a repeat head imaging, vasogenic edema (P = 0.023) and subcortical white matter lesions (P = 0.011) were significantly higher in patients with SE than those without SE, while hematoma growth (P = 0.000), infarction progress (P = 0.003), and recurrent subarachnoid hemorrhage (SAH) (P = 0.011) were significantly lower in patients with SE than those without SE. Patients with SE had higher adjusted rates of fever ≥ 39 °C (odds ratio (OR): 2.753; 95% confidence interval (CI): 1.116 - 6.794; P = 0.028) and SIRS ≥ 3 items (OR: 6.459; 95% CI: 2.050 - 20.351; P = 0.001). The 30-day mortality in stroke patients with SE was higher than those without SE (76.1% vs. 45.8%, P = 0.003). CONCLUSION: High fever and severe SIRS are two early predictors of stroke patients with SE, and survival rates were worse in stroke patients with SE than those without SE.

Hemorrhagic pure sensory strokes in the thalamus and striatocapsular area: causes, clinical features and long-term outcome.

BACKGROUND: Although there have been sporadic reports of patients with hemorrhagic pure sensory strokes (HPSS) in the thalamus and striatocapsular areas, the causes, clinical featuring and long-term outcome have not been adequately investigated. METHODS: We recruited 7 consecutive patients without hemiparetic stroke who had HPSS in the thalamic and striatocapsular areas. A CT scan was performed to verify brain imaging patterns, and their causes, clinical featuring and long-term outcome were observed. RESULTS: We studied 7 patients who had HPSS in the thalamic and striatocapsular areas as seen in CT scans. The 7 patients had hypertension, and small hemorrhages were found in the thalamus of 2 patients and in the posterior quarter of the posterior limb of the internal capsule in 4 patients; only 1 patient had a microhemorrhage in the thalamus. The volume of the hemorrhages ranged from 0.3 to 6.3 ml, with a mean of 2.3 ± 1.9 ml. Three patients showed a decreased sense of spinothalamic modality, and position and vibration senses were spared. Four patients showed a sensory deficit of both spinothalamic and medial lemniscal type. The outcomes were excellent and without post-stroke pain in all patients. CONCLUSION: HPSS in the thalamus and striatocapsular area are usually small hemorrhages or microhemorrhages from rupturing of the microvessels or the branches of small vessels. HPSS only have an impact on the adjacent sensory nucleus or pathway, and have a good outcome without post-stroke pain.

Pure sensory stroke from compression of putaminal haemorrhage: a case report.

INTRODUCTION: The literature rarely describes putaminal haemorrhage producing pure spinothalamic sensory deficit. Here reports a case of putaminal haemorrhage in which selective impairment of the spinothalamic sensory modality was due to the compression of the hematoma. CASE PRESENTATION: A 57 year old hypertensive man presented with a pure sensory stroke(PSS), and CT scan showed a putaminal haemorrhage. The clinical course was characterized by rapid resolution of the deficits. CONCLUSION: This case illustrates this rarely of PSS from compression of putaminal haemorrhage of good functional and vital prognosis, and stresses the value of CT scanning for diagnosis and prognosis.