Changes Over 7 Years in Temperature Control Treatment and Outcomes After Out-of-Hospital Cardiac Arrest: A Japanese, Multicenter Cohort Study.

Temperature control is the only neuroprotective intervention suggested in current international guidelines for patients with return of spontaneous circulation after cardiac arrest, but the prevalence of temperature control therapy, temperature settings, and outcomes have not been clearly reported. We aimed to investigate changes over 7 years in provision of temperature control treatment among out-of-hospital cardiac arrest (OHCA) patients in Kanto region, Japan. Data of all adult OHCA patients who survived for more than 24 hours in the prospective cohort studies, SOS-KANTO 2012 (conducted from 2012 to 2013) and SOS-KANTO 2017 (conducted from 2019 to 2021), in Japan were included. We compared the prevalence of temperature control and the proportion of mild (≥35°C) and moderate (from 32°C to 34.9°C) hypothermia between the two study groups. We also performed a Cox regression analysis to evaluate 30-day mortality adjusted by temperature control therapy (none, moderate hypothermia, or mild hypothermia), age, sex, past medical history, witnessed status, bystander cardiopulmonary resuscitation, initial rhythm, location of arrest, and dataset (SOS-KANTO 2012 or 2017). We analyzed data from 2936 patients (n = 1710, SOS-KANTO 2012; n = 1226, SOS-KANTO 2017). Use of temperature control was lower (45.3% vs. 41.4%, p = 0.04), moderate hypothermia was lower (p < 0.01), and mild hypothermia was higher (p < 0.01) in SOS-KANTO 2017 compared with SOS-KANTO 2012. The survival rate was significantly higher for patients with mild (p < 0.01) and moderate (p < 0.01) hypothermia compared with those who did not receive temperature control therapy. Overall, the incidence of moderate hypothermia decreased and that of mild hypothermia increased and the use of temperature control decreased between the two studies conducted 7 years apart in the Kanto area, Japan. Temperature control management might improve survival of patients with OHCA.

Evaluation of clinical response to empirical antimicrobial therapy on day 7 and mortality in the intensive care unit: sub-analysis of the DIANA study Japanese data.

It is not clear whether evaluating the clinical response to antibiotic use at day 7 among critically ill patients accurately predicts outcomes. We aimed to evaluate the relationship between clinical response to the initial empiric therapy on day 7 and mortality. Methods: The determinants of antimicrobial use and de-escalation in critical care (DIANA) study was an international, multicenter, observational study on antibiotic use in the intensive care unit (ICU). ICU patients ages over 18 years in whom an empiric antimicrobial regimen in Japan was initiated were included. We compared patients who were evaluated as cured or improved ("effective") 7 days after starting antibiotic treatment with patients who were evaluated as deteriorated ("failure"). Results: Overall, 217 (83%) patients were in the effective group, and 45 (17%) were in the failure group. Both the infection-related mortality rate in the ICU and the in-hospital infection-related mortality rate in the effective group were lower than those in the failure group (0% versus 24.4%; P < 0.01 and 0.5% versus 28.9%; P < 0.01, respectively). Conclusion: Assessment of efficacy of empiric antimicrobial treatment on day 7 may predict a favorable outcome among patients suffering from infection in the ICU.

Levetiracetam versus fosphenytoin as a second-line treatment after diazepam for adult convulsive status epilepticus: a multicentre non-inferiority randomised control trial.

OBJECTIVE: Status epilepticus (SE) is an emergency condition for which rapid and secured cessation is crucial. Although fosphenytoin (FPHT) is recommended as a second-line treatment, levetiracetam (LEV) reportedly has similar efficacy, but higher safety. Therefore, we herein compared LEV with FPHT in adult SE. METHODS: We initiated a multicentre randomised control trial in emergency departments with adult patients with convulsive SE. Diazepam was initially administered, followed intravenously by FPHT at 22.5 mg/kg or LEV at 1000-3000 mg. The primary outcome was assigned as the seizure cessation rate within 30 min of the administration of the study drug. RESULTS: A total of 176 adult patients with SE were enrolled (82 FPHT and 94 LEV), and 3 were excluded from the full analysis set. Seizure cessation rates within 30 min were 83.8% (67/80) in the FPHT group and 89.2% (83/93) in the LEV group. The difference in these rates was 5.5% (95% CI -4.7 to 15.7, p=0.29). The non-inferiority of LEV to FPHT was confirmed with p<0.001 by the Farrington-Manning test. No significant differences were observed in the seizure recurrence rate or intubation rate within 24 hours. Serious adverse events developed in three patients in the FPHT group and none in the LEV group (p=0.061). CONCLUSION: The efficacy of LEV was similar to that of FPHT for adult SE following the administration of diazepam. LEV may be recommended as a second-line treatment for SE along with phenytoin/FPHT. TRIAL REGISTRATION NUMBER: jRCTs031190160.

Neurointensive Care of Traumatic Brain Injury Patients Based on Coagulation and Fibrinolytic Parameter Monitoring.

Coagulopathy, a common complication of traumatic brain injury (TBI), is characterized by a hypercoagulable state developing immediately after injury, with hyperfibrinolysis and bleeding tendency peaking 3 h after injury, followed by fibrinolysis shutdown. Reflecting this timeframe, the coagulation factor fibrinogen is first consumed and then degraded after TBI, its concentration rapidly decreasing by 3 h post-TBI. The fibrinolytic marker D-dimer reaches its maximum concentration at the same time. Hyperfibrinolysis in the acute phase of TBI is associated with poor prognosis via hematoma expansion. In the acute phase, the coagulation and fibrinolysis parameters must be monitored to determine the treatment strategy. The combination of D-dimer plasma level at admission and the level of consciousness upon arrival at the hospital can be used to predict the patients who will "talk and deteriorate." Fibrinogen and D-dimer levels should determine case selection and the amount of fresh frozen plasma required for transfusion. Surgery around 3 h after injury, when fibrinolysis and bleeding diathesis peak, should be avoided if possible. In recent years, attempts have been made to estimate the time of injury from the time course of coagulation and fibrinolysis parameter levels, which has been particularly useful in some cases of pediatric abusive head trauma patients.

Comparison of the effectiveness of pericardiocentesis and surgical pericardiotomy in the prognosis of patients with blunt traumatic cardiac tamponade: a multicenter study using the Japan Trauma Data Bank.

Aim: To compare the prognostic impact of pericardiocentesis (PCC) and surgical pericardiotomy (SP) in blunt traumatic pericardial tamponade. Methods: Among 361,706 trauma patients registered in the Japan Trauma Data Bank from January 2004 to December 2018, we included those with blunt traumatic cardiac tamponade who underwent PCC and/or SP. We excluded patients with penetrating trauma, age younger than 15 years, Injury Severity Score (ISS) equal to 75, blood pressure 0 mmHg at the time of admission, head Abbreviated Injury Scale (AIS) score 5 or more, and those with missing data for outcomes. To examine the effect of SP, patients were divided into a PCC group and an SP-only group. Missing values of age, sex, systolic blood pressure, respiratory rate, pulse rate, time from emergency call to hospital arrival, head AIS, chest AIS, abdomen/pelvis AIS, Glasgow Coma Scale score, and ISS were estimated using multiple imputation. In-hospital mortality was analyzed using multivariable analysis, and we undertook a survival analysis. Results: We analyzed 305 patients, 150 (49.2%) in the PCC group and 155 (50.8%) in the SP-only group. The in-hospital mortality rate was 40.7% in the PCC group and 76.8% in the SP-only group. Multivariable analysis after multiple imputation showed an odds ratio of SP for in-hospital mortality 5.34 (95% confidence interval, 2.80-10.18; P < 0.01) compared with PCC. Using the Kaplan-Meier method, SP showed a significant risk of mortality (hazard ratio 2.16; 95% confidence interval, 1.58-2.95; P < 0.01). Conclusions: In patients with blunt traumatic cardiac tamponade, SP was associated with poor prognosis.

Utility of a Compatibility Chart for Continuous Infusions in the Intensive Care Unit.

BACKGROUND: In the intensive care unit (ICU), multiple intravenous drugs are often administered through the same catheter line, greatly increasing the risk of drug incompatibility. We previously developed a compatibility chart including 27 drugs and have used it to avoid drug incompatibilities in the ICU. This retrospective study evaluated the utility of this chart by analyzing prescriptions and incidents of incompatibilities in an ICU. METHODS: We analyzed 257 ICU prescriptions of two or more continuous infusions on the same day during the period between March 2016 and February 2017 and investigated the rate of compliance with the compatibility chart. Drug combinations were classified as "compatible," "tolerable compatible," "incompatible," and "no data." For all combinations, the compliance rate was defined as the ratio of compatible and tolerable compatible combinations. Additionally, using our hospital incident report database, we analyzed 27,117 injections administered in the ICU between March 2016 and February 2017 and investigated incidents related to incompatibility. RESULTS: Three hundred infusion combinations were identified in the prescriptions. The compliance rate was 97% (n = 293). Of the 113 combinations judged to be tolerable compatible, 98% (n = 111) consisted of three or more continuous medications injected through the same intravenous line. Of the two incidents related to incompatibility in the incident report database, the combination "nicardipine and furosemide" was defined as incompatible in the compatibility chart. CONCLUSIONS: The high rate of compliance with the compatibility chart suggested it was useful in preventing drug incompatibility.

Effect of angioembolization for isolated complex pelvic injury: A post-hoc analysis of a nationwide multicenter trauma database in Japan.

BACKGROUND AND IMPORTANCE: Complex pelvic injuries are among the types of trauma with the highest mortality. Treatment strategies should be based on the hemodynamic status, the anatomical type of fracture, and the associated injuries. Combination therapies, including preperitoneal pelvic packing, temporary mechanical stabilization, resuscitative endovascular balloon occlusion of the aorta, and angioembolization, are recommended for pelvic injuries. OBJECTIVE: To investigate the effect of urgent angioembolization alone on severe pelvic injury-associated mortality. DESIGN, SETTINGS, AND PARTICIPANTS: We used the Japan Trauma Data Bank database, a multicenter observational study, to retrospectively identify adult patients with isolated blunt pelvic injuries (Abbreviated Injury Scale [AIS] score: 3-5) from 2004 to 2018. OUTCOME MEASURES AND ANALYSIS: The primary outcome measure was in-hospital mortality. We subdivided patients into two groups, those who underwent urgent angioembolization and non-urgent angioembolization, and compared their mortality rates. We performed multiple imputation and multivariable analyzes to compare the mortality rates between groups after adjusting for known potential confounding factors (age, sex, Glasgow Coma Scale score, systolic blood pressure on hospital arrival, Injury Severity Score, pelvic AIS score, laparotomy, resuscitative endovascular balloon occlusion of the aorta, and external fixation) and for within-hospital clustering using the generalized estimating equation. MAIN RESULTS: We analyzed 4207 of 345,932 trauma patients, of whom 799 underwent urgent angioembolization. The in-hospital mortality rate was significantly higher in the urgent embolization group than in the non-urgent embolization group (7.4 vs. 4.0%; p < 0.01). However, logistic regression analysis revealed that the mortality rates of patients with urgent angioembolization significantly decreased after adjusting for factors independently associated with mortality (odds ratio: 0.60; 95% confidence interval: 0.37-0.96; p = 0.03). CONCLUSION: Urgent angioembolization may be an effective treatment for severe pelvic injury regardless of the pelvic AIS score and the systolic blood pressure on hospital arrival.

Elective Endovascular Stent-Graft Implantation for External Iliac Artery Injury after Blunt Pelvic Trauma.

External iliac artery (EIA) injuries caused by blunt trauma are rare. Here, we describe a blunt EIA injury after a motorbike accident suffered by a 16-year-old male. Despite conservative treatment, intermittent claudication persisted. He was successfully treated by elective endovascular stent-graft implantation on day 59 after the injury. Ankle-brachial index (ABI) improved, as did his symptoms. A contrast-enhanced computed tomography scan on postoperative day 90 showed no residual stenosis and favorable peripheral blood flow. This report suggests that elective endovascular stent-graft implantation might be a viable treatment option for blunt EIA injuries.

Association between mortality and age among mechanically ventilated COVID-19 patients: a Japanese nationwide COVID-19 database study.

BACKGROUND: Only a few studies have reported the association between age and mortality in COVID-19 patients who require invasive mechanical ventilation (IMV). We aimed to evaluate the effect of age on COVID-19-related mortality among patients undergoing IMV therapy. METHODS: This cohort study was conducted using the COVID-19 Registry Japan database, a nationwide multi-centre study of hospitalized patients with laboratory-confirmed COVID-19. Of all 33,808 cases registered between 1 January 2020 to 28 February 2021, we analysed 1555 patients who had undergone IMV. We evaluated mortality rates between age groups using multivariable regression analysis after adjusting for known potential components, such as within-hospital clustering, comorbidities, steroid use, medication for COVID-19, and vital signs on admission, using generalized estimation equation. RESULTS: By age group, the mortality rates in the IMV group were 8.6%, 20.7%, 34.9%, 49.7% and 83.3% for patients in their 50s, 60s, 70s, 80s, and 90s, respectively. Multivariable analysis showed that compared with those for patients aged < 60 years, the odds ratios (95% confidence interval) of death were 2.6 (1.6-4.1), 6.9 (4.2-11.3), 13.2 (7.2-24.1), 92.6 (16.7-515.0) for patients in their 60s, 70s, 80s, and 90s, respectively. CONCLUSIONS: In this cohort study, age had a great effect on mortality in COVID-19 patients undergoing IMV, after adjusting for variables independently associated with mortality. This study suggested that age was associated with higher mortality and that preventing progression to severe COVID-19 in elderly patients may be a great public health issue.

Ultra-Early Induction of General Anesthesia for Reducing Rebleeding Rates in Patients with Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Rebleeding of aneurysmal subarachnoid hemorrhage (aSAH) is one of the significant risk factors for poor clinical outcome. The rebleeding risk is the highest during the acute phase with an approximate rebleeding rate of 9-17% within the first 24 h. Theoretically, general anesthesia can stabilize a patient's vital signs; however, its effectiveness as initial management for preventing post-aSAH rebleeding remains unclear. The purpose of this study was to determine the feasibility and safety of ultra-early general anesthesia induction for reducing the rebleeding rates among patients with aSAH. MATERIALS AND METHODS: We retrospectively evaluated patients with aSAH who were admitted to our department between January 2013 and December 2019. All the patients underwent ultra-early general anesthesia induction as initial management regardless of their severity. We evaluated the rebleeding rate before definitive treatment, factors influencing rebleeding, and general anesthesia complications. RESULTS: We included 191 patients with two-third of them having a poor clinical grade (World Federation of Neurological Society [WFNS] grade IV or V). The median duration from admission to general anesthesia induction was 22 min. Rebleeding before definitive treatment occurred in nine patients (4.7%). There were significant differences in the Glasgow Coma Scale score (p = 0.047), WFNS grade (p = 0.02), and dissecting aneurysm (p <0.001) between the rebleeding and non-rebleeding patients. There were no cases of unsuccessful tracheal intubation or rebleeding during general anesthesia induction. CONCLUSION: Ultra-early general anesthesia induction could be performed safely in patients with aSAH, regardless of the WFNS grade; moreover, it resulted in lower rebleeding rate than that reported in previous epidemiological reports.

Blood concentration of levetiracetam after bolus administration in patients with status epilepticus.

PURPOSE: We aimed to evaluate the blood concentration of levetiracetam (LEV), as a second-line drug, in patients with status epilepticus (SE) in an emergency clinical setting. METHODS: We prospectively evaluated 20 consecutive patients with SE admitted to our department between July 2017 and July 2019. LEV (2500 mg) was administered via bolus infusion after diazepam infusion, followed by 500 mg every 12 h for 48 h and then 500 mg orally. The primary outcomes were LEV blood concentration 15 min, 12 h, 48 h, and 96 h after administration and the proportion of patients showing trough LEV concentration within the therapeutic range. The secondary outcomes were the discontinuation of apparent convulsive seizure, epileptic wave on electroencephalogram, tracheal intubation, adverse events related to blood parameters, and abnormal findings in vital signs examination. RESULTS: Median blood LEV (2500 mg) concentration at 15 min after administration was 81.6 µg/mL. The median trough concentration after 12, 48, and 96 h was 28.8, 10.5, and 9.1 µg/mL, respectively. Moreover, 95% of patients had trough concentration above the lower limit of the therapeutic blood concentration (>12 µg/mL) after 12 h. Regarding secondary outcomes, endotracheal intubation, seizure suppression, and abnormal electroencephalogram findings were observed in approximately 40%, 90%-95%, and 41% of patients, respectively. No abnormal findings were noted in blood tests and vital sign examination, although the AST/ALT levels increased in 10% of the patients. CONCLUSION: After bolus administration of 2500 mg, the blood LEV concentration reached the therapeutic window in patients with early-stage SE.

Validation of sepsis-induced coagulopathy score in critically ill patients with septic shock: post hoc analysis of a nationwide multicenter observational study in Japan.

Coagulation disorder is a major cause of death in sepsis patients. Recently, sepsis-induced coagulopathy (SIC) scoring was developed as a new criterion for coagulopathy-associated sepsis. We aimed to evaluate the accuracy of the SIC score for predicting the prognosis of septic shock. We analyzed data from a multicenter observational study conducted from 2011 to 2013. We grouped the participants into those who did and did not use vasopressors, and compared the in-hospital mortality rates of SIC and non-SIC patients. Patients who needed vasopressors were considered to have septic shock. We performed survival analysis adjusted by factors independently associated with mortality. SIC developed in 66.4% of patients who used vasopressors and 42.2% of patients who did not. The in-hospital mortality difference between the SIC and non-SIC groups was statistically significant in those who needed vasopressors (35.8% vs 27.9%, p < 0.01). Cox regression analysis indicated that SIC was significantly correlated with mortality risk in patients who used vasopressors (hazard ratio [HR] 1.39; 95% confidence interval [CI] 1.13-1.70; p < 0.01), but not in those who did not (HR 1.38; 95% CI 0.81-2.34; p = 0.23). In conclusion, the SIC score might be a good diagnostic indicator of fatal coagulopathy among sepsis patients who need vasopressors.

Endovascular treatment of acute basilar artery occlusion: Outcomes, influencing factors and imaging characteristics from the Tama-REgistry of acute thrombectomy (TREAT) study.

OBJECTIVE: The effectiveness of mechanical thrombectomy (MT) for acute basilar artery occlusion (ABAO) remains unknown. We evaluated the feasibility, safety, and efficacy of endovascular treatment for ABAO. METHODS: We retrospectively investigated patients with ABAO who underwent MT using modern stent retrievers and an aspiration device between January 2015 and March 2019 at 12 comprehensive stroke centers. Functional outcomes and 90-day mortality rates were analyzed as primary outcomes. Factors influencing outcomes were analyzed as secondary outcomes. Relationships between outcome and affected area of infarction on arrival were also analyzed. RESULTS: Seventy-three patients were included. Good outcome (modified Rankin Scale (mRS) score 0-2) was achieved in 25/73 patients (34.2%) and the all-cause 90-day mortality rate was 23.3% (17/73). Successful recanalization (modified Thrombolysis In Cerebral Infarction grade 2b and 3) was achieved in 70/73 patients (95.9%). In univariate analyses, age, National Institutes of Health Stroke Scale score, and posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) differed significantly between good and poor functional outcome groups. Age and pc-ASPECTS were significantly associated with functional outcomes in the logistic regression model. Positive findings for the midbrain on diffusion-weighted imaging on pc-ASPECTS and brainstem score were significantly associated with poor outcomes. CONCLUSION: MT with modern devices for ABAO resulted in highly successful recanalization and good outcomes. A positive finding for the midbrain on initial imaging might predict poor outcomes. Further studies are required to confirm our results.

Head positioning in suspected patients with acute stroke from prehospital to emergency department settings: a systematic review and meta-analysis.

AIM: This study aimed to clarify whether the lying-flat position from prehospital to emergency department settings more effectively improves neurological outcomes of patients suspected with acute stroke over the sitting-up position. METHODS: We searched PubMed, the Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi for published randomized controlled trials until September 2019. The study population included patients suspected with acute stroke from prehospital to emergency department settings. We compared outcomes between the lying-flat position and sitting-up position groups. The critical outcome was the modified Rankin Scale score at 90 days, and important composite outcomes were 90-day mortality, pneumonia recurrence, and recurrent ischemic stroke. The certainty of evidence of the outcome level was compared using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS: In total, 881 studies were identified from the databases, and two randomized controlled trials were included in the analysis. The pooled risk ratio of 90-day modified Rankin Scale score was not statistically significant (risk ratio 0.86; 95% confidence interval [CI] 0.56-1.32) between the lying-flat position and sitting-up position groups. When comparing the 90-day mortality, pneumonia occurrence, and recurrent ischemic stroke, no significant differences were observed between the two groups. Risk ratio was 1.00 (95% CI 0.87-1.14), 0.90 (95% CI 0.74-1.11), and 0.81 (95% CI 0.14-4.64) for 90-day mortality, pneumonia occurrence, and recurrent ischemic stroke, respectively. CONCLUSION: This study suggests that the lying-flat position is not more effective than the sitting-up position in terms of 90-day modified Rankin Scale score in patients suspected with acute stroke.

Treatment of Geriatric Traumatic Brain Injury: A Nationwide Cohort Study.

BACKGROUND: Because of the aging of the Japanese population, traumatic brain injuries (TBI) have increased in elderly adults. However, the effectiveness and prognosis of intensive treatment for geriatric TBI have not yet been determined. Thus, we used nationwide data from the Japan Neurotrauma Data Bank (JNTDB) projects to analyze prognostic factors for intensive and aggressive treatments. METHODS: We analyzed 1,879 geriatric TBI cases (age ≥65 years) registered in four JNTDB projects: Project 1998 (P1998) to Project 2015 (P2015). Clinical features, use of aggressive treatment, and 6-month outcomes on the Glasgow Outcome Scale (GOS) were compared among study projects. Logistic regression was used to identify prognostic factors in aggressively treated patients. RESULTS: The percentage of geriatric TBI cases significantly increased with time-P1998: 30.1%; Project 2004 (P2004): 34.6%; Project 2009 (P2009): 43.9%; P2015: 53.6%, p<0.0001). Use of aggressive treatment also significantly increased, from 67.0% in P1998 to 69.3% in P2015 (p<0.0001). Less invasive methods, such as trepanation and normothermic targeted temperature management, were more often chosen for geriatric patients. These efforts resulted in a significant decrease in the 6-month mortality rate, from 76.2% in P1998 to 63.1% in P2015 (p=0.0003), although the percentage of severely disabled patients increased, from 8.9% in P1998 to 11.1% in P2015 (p=0.0003). Intraventricular hemorrhage was the factor most strongly associated with unfavorable 6-month outcomes (OR 3.79, 95% CI 1.78-8.06, p<0.0001). CONCLUSIONS: Less invasive treatments reduced mortality in geriatric TBI but did not improve functional outcomes. Patient age was not the strongest prognostic factor; thus, physicians should consider characteristics other than age.

Early versus late surgery after cervical spinal cord injury: a Japanese nationwide trauma database study.

BACKGROUND: The management of cervical spinal cord injury (SCI) has changed drastically in the last decades, and surgery is the primary treatment. However, the optimum timing of early surgical treatment (within 24 h or 72 h after injury) is still controversial. We sought to determine the optimum timing of surgery for cervical SCI, comparing the length of the intensive care unit (ICU) stay and in-hospital mortality in patients who underwent surgical treatments (decompression and stabilization) for cervical SCI within 24 h after injury and within 7 days after injury. METHODS: This was a retrospective cohort study using Japan Trauma Data Bank (JTDB) which is a nationwide, multicenter database. We selected adult isolated cervical SCI patients who underwent operative management within 7 days after injury, between 2004 and 2015. The main outcome measures were the length of ICU stay and in-hospital mortality. We grouped the patients into two, based on the time from onset of injury to surgery, an early group (within 24 h) and a late group (from 25 h to 7 days). Next, we performed multivariable analyses for analyzing the relevance between the timing of surgery and the length of ICU stay after adjusting for baseline characteristics using propensity score. We also performed the Cox survival analyses to evaluate in-hospital mortality. RESULTS: From 236,698 trauma patients registered in JTDB, we analyzed 514 patients. The early group comprised 291 patients (56.6%), and the late group comprised 223 (43.4%). The length of ICU stay did not differ between the two groups (early, 10 days; late, 11 days; p = 0.29). There was no significant difference for length of ICU stay between the early and late group even after adjustment by multivariate analysis (p = 0.64). There was no significant difference in in-hospital mortality between the two groups (the early group 3.8%, the late group 2.2%, p = 0.32), and no significant difference was found in the Cox survival analysis. CONCLUSIONS: Our study showed that neither the length of ICU stay nor in-hospital mortality after spinal column stabilization or spinal cord decompression for cervical SCI significantly differed according to the timing of surgery between 24 h and 7 days.

Intracranial pressure management and neurological outcome for patients with mild traumatic brain injury who required neurosurgical intervention: a Japanese database study.

Purpose: Among mild traumatic brain injuries (mTBI; a Glasgow Coma Scale score ≥13 on arrival), few result in severe neurological deficit, especially when they needed neurosurgical intervention. We investigated the association of intracranial pressure (ICP) control management with neurological outcome in patients with mTBI who needed neurosurgical intervention. Methods: From 1,092 records of the Japan Neurotrauma Data Bank during 2009-2011, we retrospectively identified 195 patients with neurosurgical intervention for mTBI. Using the Glasgow Outcome Scale, we grouped records into two: favorable and poor outcome. We analyzed neurological outcomes using a logistic regression analysis adjusted for ICP control managements. Results: Seventy patients had a poor outcome. Logistic regression analysis revealed that sedatives, hyperosmotic agents, and hyperventilation therapy were significantly associated with poor outcome (odds ratio [OR]: 2.36, 95% confidence interval [CI]: 1.31-4.26; OR: 2.81, 95% CI: 1.17-6.75; OR: 9.36, 95% CI: 1.81-48.35). However, temperature management was significantly related with favorable outcome (OR: 0.26, 95% CI: 0.10-0.66). Conclusions: Our study, using a Japanese multicenter brain trauma registry, suggested that requirement of sedatives, hyperosmotic agents, and hyperventilation is associated with poor neurological outcome for patients with mTBI who underwent neurosurgical intervention, although temperature management was associated with favorable neurological outcome.

Functional Outcome Following Ultra-Early Treatment for Ruptured Aneurysms in Patients with Poor-Grade Subarachnoid Hemorrhage.

BACKGROUND: Little is known regarding functional outcome following poor-grade (World Federation of Neurosurgical Societies grades IV and V) aneurysmal subarachnoid hemorrhage (aSAH), especially in individuals treated aggressively in the early phase after ictus. METHODS: We provided patients with aSAH with ultra-early definitive treatment, coiling or clipping, within 6 hours from arrival as per protocol. We classified the patients into 3 groups according to their computed tomography findings: Group 1, intraventricular hemorrhage with obstructive hydrocephalus; Group 2, massive intracerebral hemorrhage with brain herniation; and Group 3, neither Group 1 nor Group 2. We retrospectively evaluated patients with poor-grade aSAH who were admitted to our department between January 2013 and December 2016. We evaluated functional outcome at 6 months, defining modified Rankin Scale (mRS) scores of 0-2 as good and those of 3-6 as poor outcomes. RESULTS: A good functional outcome was observed in 39.4% (28/71) of all cases. All-cause mortality at 6 months was 15.5% (11/71). A good outcome in Group 3 was significantly higher than that in the other two groups (Group 1 and 2 vs. Group 3, 20.8% vs. 48.9%, p = 0.02), even after adjustment with a multiple logistic regression analysis (odds ratio 6.1, 95% confidence interval 1.1 to 34.8). CONCLUSIONS: Approximately 40% of patients with poor-grade aSAH became functionally independent, and approximately half of the patients with poor-grade aSAH who had neither intraventricular hemorrhage with obstructive hydrocephalus nor with brain herniation had good functional outcomes. Although further trials are required to confirm our results, ultra-early surgery may be considered for patients with poor-grade aSAH.

Endovascular treatment of acute basilar artery occlusion: Tama-REgistry of Acute Thrombectomy (TREAT) study.

OBJECTIVE: The effectiveness of mechanical thrombectomy (MT) for acute basilar artery occlusion (ABAO) remains unknown. We evaluated the feasibility, safety, and efficacy of endovascular treatment for ABAO. METHODS: We retrospectively investigated patients with ABAO who underwent MT, using modern stent retrievers and an aspiration device, between January 2015 and December 2017 at 12 comprehensive stroke centers. Functional outcomes and 90-day mortality were analyzed as primary outcomes. RESULTS: Forty-eight patients were included. Good outcome (modified Rankin Scale mRS 0-2) was achieved in 20/48 patients and the all-cause 90-day mortality rate was 25%. Successful recanalization (modified Thrombolysis In Cerebral Infarction [mTICI] grade 2b and 3) was achieved in 47/48 patients. National Institutes of Health Stroke Scale, posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS), DWI Brain Stem Score, mTICI (3 > 2b), and intracranial hemorrhage were significantly different between good and poor functional outcome groups. The occlusion site of BA was significantly different between patients with moderate outcome (mRS 0-3) versus others. We found that age, pc-ASPECTS and mTICI were significantly associated with functional outcomes in the logistic regression model. CONCLUSION: MT with stent retrievers and an aspiration device for ABAO results in high successful recanalization and good outcomes. Further studies are required to confirm our results.

Feasibility and Safety of Intravascular Temperature Management for Severe Heat Stroke: A Prospective Multicenter Pilot Study.

OBJECTIVES: Heat stroke is a life-threatening condition with high mortality and morbidity. Although several cooling methods have been reported, the feasibility and safety of treating heat stroke using intravascular temperature management are unclear. This study evaluated the efficacies of conventional treatment with or without intravascular temperature management for severe heat stroke. DESIGN: Prospective multicenter study. SETTING: Critical care and emergency medical centers at 10 tertiary hospitals. PATIENTS: Patients with severe heat stroke hospitalized during two summers. INTERVENTIONS: Conventional cooling with or without intravascular temperature management. MEASUREMENTS AND MAIN RESULTS: Cooling efficacy, Sequential Organ Failure Assessment score, occurrence rate of serious adverse events, and prognosis based on the modified Rankin Scale and Cerebral Performance Category. Patient outcomes were compared between five centers that were prospectively assigned to perform conventional cooling (control group: eight patients) and five centers that were assigned to perform conventional cooling plus intravascular temperature management (intravascular temperature management group: 13 patients), based on equipment availability. Despite their higher initial temperatures, all patients in the intravascular temperature management group reached the target temperature of 37°C within 24 hours, although only 50% of the patients in the control group reached 37°C (p < 0.01). The intravascular temperature management group also had a significant decrease in the Sequential Organ Failure Assessment score during the first 24 hours after admission (4.0 vs 1.5; p = 0.04). Furthermore, the intravascular temperature management group experienced fewer serious adverse events during their hospitalization, compared with the control group. The percentages of favorable outcomes at discharge and 30 days after admission were not statistically significant. CONCLUSIONS: The combination of intravascular temperature management and conventional cooling was safe and feasible for treating severe heat stroke. The results indicate that better temperature management may help prevent organ failure. A large randomized controlled trial is needed to validate our findings.