Frank Rasulo

Emergent decompressive craniectomy in patients with fixed dilated pupils due to cerebral venous and dural sinus thrombosis: report of three cases.

OBJECTIVE AND IMPORTANCE Cerebral venous and dural sinus thrombosis is a rare cause of stroke. Although morbidity and mortality have greatly decreased in recent years as a result of early diagnosis and timely medical treatment, when coma occurs the prognosis remains poor. We evaluated whether emergent decompressive craniectomy has a role in the treatment of patients with brain herniation from dural sinus thrombosis and hemorrhagic infarct. CLINICAL PRESENTATION Three patients developed large hemorrhagic infarct with coma and bilaterally fixed and dilated pupils resulting from aseptic dural sinus thrombosis. INTERVENTION Two patients underwent emergent surgical decompression as soon as brain herniation developed, and these patients had complete functional recovery. One underwent delayed surgical decompression and remained severely disabled. CONCLUSION Our results provide preliminary evidence that emergent decompressive craniectomy is effective in patients with brain herniation from dural sinus thrombosis, provided that the clinical onset is recent. We therefore recommend consideration of this aggressive surgical technique for such patients, who may survive with good outcomes.

Presentation and management of ICU myopathy and neuropathy.

Purpose of reviewCritical illness myopathy and neuropathy are common complications in the ICU, causing limb and respiratory muscle weakness. We review the most recent data concerning their presentation, diagnosis and treatment. Recent findingsLimb muscle strength can be reliably assessed by using the Medical Research Council scale or handgrip dynamometry. A Medical Research Council sum score below 48 or mean Medical Research Council score below 4 (antigravity strength) across all testable muscle groups, and a force value of less than 11 kg-force for men and less than 7 kg-force for women at dominant-hand dynamometry identify ICU-acquired weakness in previously healthy individuals admitted to an ICU for nonneuromuscular disorder. Clinical signs, together with measurements of the maximal inspiratory and expiratory pressures and vital capacity, are important to timely diagnose respiratory muscle weakness. Electrophysiological testing is usefully implemented in unconscious patients or in awake patients who do not improve despite appropriate treatments. Early physiotherapy in the ICU can increase the proportion of patients reaching an independent functional status following their ICU stay. Critical illness myopathy and neuropathy may occur outside the ICU; however, exact estimates are lacking. SummarySystematic application of diagnostic criteria and early physiotherapy may help clinicians to timely diagnose critical illness myopathy and neuropathy and to reduce the associated morbidity.

Quality of reporting of randomized controlled trials published in Intensive Care Medicine from 2001 to 2010

PurposeTo evaluate the methodological quality of randomized controlled trials (RCTs) published in Intensive Care Medicine from 2001 to 2010, and to compare it with a previous review of RCTs published from 1975 to 2000.MethodsWe assessed the quality of reporting of randomization, blinding and participant flow, both individually and combined within the Jadad scale, and compared them with findings from our previous review. For RCTs published from 2001 to 2010, we also evaluated the frequency of distorted finding presentation (spin) and inflated predicted treatment effect (delta inflation).ResultsIn the 221 RCTs from 2001 to 2010, the sample size was significantly larger than in the older series, and there was a higher proportion of studies with negative findings. Reporting of the rationale for sample size estimation and allocation concealment increased significantly, but reporting of other important individual methodological components did not change substantially compared with the previous period and remained low. Among RCTs from 2001 to 2010, a spin strategy was used in 69 of 111 RCTs with statistically negative results, while delta inflation was present in 7 of 11 RCTs evaluating survival as a primary outcome. Papers with higher Jadad scores were cited more often than the others.ConclusionsQuality of reporting of RCTs published in Intensive Care Medicine has only partly improved over time, and spin and delta bias are of frequent occurrence. There is a need for stronger adherence to CONSORT recommendations, with special emphasis on accurate description of randomization and blindness, and correct reporting of statistically non-significant results.

Cerebrovascular reactivity and autonomic drive following traumatic brain injury

INTRODUCTION The autonomic nervous system exerts tonic control on cerebral vessels, which in turn determine the autoregulation of cerebral blood flow. We hypothesize that the impairment of cerebral autoregulation following traumatic brain injury might be related to the acute failure of the autonomic system. METHODS This prospective, observational study included patients with severe traumatic brain injury requiring mechanical ventilation and invasive monitoring of intracranial pressure (ICP) and arterial blood pressure (ABP). Pressure reactivity index (PRx), a validated index of cerebrovascular reactivity, was continuously monitored using bedside computers. Autonomic drive was assessed by means of heart rate variability (HRV) using frequency domain analysis. FINDINGS Eighteen TBI patients were included in the study. Cerebrovascular reactivity impairment (PRx above 0.2) and autonomic failure (low spectral power of HRV) are significantly and independently associated with fatal outcome (P = 0.032 and P < 0.001, respectively). We observed a significant correlation between PRx and HRV spectral power (P < 0.001). The high frequency component of HRV (HF, 0.15-0.4Hz) can be used to predict impaired autoregulation (PRx > 0.2), although sensitivity and specificity are low (ROC AUC = 0.67; P = 0.001). CONCLUSION Following traumatic brain injury, autonomic failure and cerebrovascular autoregulation impairment are both associated with fatal outcome. Impairment of cerebrovascular autoregulation and autonomic drive are interdependent phenomena. With some refinements, HRV might become a tool for screening patients at risk for cerebral autoregulation derangement following TBI.

Quality of reporting on the vegetative state in Italian newspapers. The case of Eluana Englaro.

Background Media coverage of the vegetative state (VS) includes refutations of the VS diagnosis and describes behaviors inconsistent with VS. We used a quality score to assess the reporting in articles describing the medical characteristics of VS in Italian newspapers. Methodology/Principal Findings Our search covered a 7-month period from July 1, 2008, to February 28, 2009, using the online searchable databases of four major Italian newspapers: Corriere della Sera, La Repubblica, La Stampa, and Avvenire. Medical reporting was judged as complete if three core VS characteristics were described: patient unawareness of self and the environment, preserved wakefulness (eyes open), and spontaneous respiration (artificial ventilator not needed). We retrieved 2,099 articles, and 967 were dedicated to VS. Of these, 853 (88.2%) were non-medical and mainly focused on describing the political, legal, and ethical aspects of VS. Of the 114 (11.8%) medical articles, 53 (5.5%) discussed other medical problems such as death by dehydration, artificial nutrition, neuroimaging, brain death, or uterine hemorrhage, and 61 (6.3%) described VS. Of these 61, only 18 (1.9%) reported all three CORE characteristics and were judged complete. We found no differences among the four investigated newspapers (Fishers exact  = 0.798), and incomplete articles were equally distributed between journalistic pieces and expert opinions (χ2 = 1.8854, P = 0.170). Incorrect descriptions of VS were significantly more common among incomplete articles (13 of 43 vs. 1 of 18; Fishers exact P = 0.047). Conclusions/Significance Core VS characteristics are rarely reported in Italian newspaper articles, which can alter adequate comprehension of new developments and (mis)inform political, legal, and ethical decisions.

Assessment of cerebral pressure autoregulation.

Cerebral pressure autoregulation, a sensitive homeostatic mechanism important for the control of cerebral blood flow, is impaired by disease pathology and some drugs commonly used during anaesthesia. Therefore, the assessment of cerebral pressure autoregulation can help optimize cerebral blood flow in patients who have suffered neurological insults. In this article, we outline the means available for testing cerebral pressure autoregulation, thus allowing the reader to decide on the best strategy to adopt in their particular operating theatre and intensive care setting.

Cerebral Blood Flow Monitoring

Abstract Brain functions strictly depend on metabolites that cannot be stored inside the brain itself. Therefore, brain perfusion is regulated to keep the flow constant according to the brain activity and within a wide range of conditions. This autoregulation may be impaired following brain injuries or strokes, so monitoring the cerebral blood flow is crucial to avoid hypoperfusion leading to ischemia. This chapter will review the several different available methods for assessing cerebral blood flow, trying to enlighten strengths and drawbacks for each monitoring.

Are you Ernest Shackleton , the polar explorer? Refining the criteria for delirium and brain dysfunction in sepsis

The Third International Consensus Definitions for Sepsis and Septic Shock has recently defined sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunctions in this consensus definition were identified as an organ-specific Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score ≥ 2 points. The quick SOFA (qSOFA) considers altered mentation indicating brain dysfunction when the Glasgow Coma Scale (GCS) score is ≤13 or ≤14. However, concern has been expressed that the revised criteria may lead to a failure in recognizing the signs of potentially lethal organ dysfunction and thus sepsis. Patients with delirium have a fluctuating course, and GCS can be normal or only slightly reduced at the time when signs of delirium are already present. We here report an illustrative case showing how an acute, initially unrecognized, urinary tract infection caused acute brain dysfunction with profound behavioral and cognitive dysfunction despite normal GCS, hence not meeting the criteria for sepsis.

Determination of Imminent Brain Death Using the Full Outline of Unresponsiveness Score and the Glasgow Coma Scale: A Prospective, Multicenter, Pilot Feasibility Study

Purpose: To evaluate the accuracy of the imminent brain death (IBD) diagnosis in predicting brain death (BD) by daily assessment of the Full Outline of Unresponsiveness (FOUR) score and the Glasgow Coma Scale (GCS) with the assessment of brain stem reflexes. Materials and Methods: Prospective multicenter pilot study carried out in 5 adult Italian intensive care units (ICUs). Imminent brain death was established when the FOUR score was 0 (IBD-FOUR) or the GCS score was 3 and at least 3 among pupillary light, corneal, pharyngeal, carinal, oculovestibular, and trigeminal reflexes were absent (IBD-GCS). Results: A total of 219 neurologic evaluations were performed in 40 patients with deep coma at ICU admission (median GCS 3). Twenty-six had a diagnosis of IBD-FOUR, 27 of IBD-GCS, 14 were declared BD, and 9 were organ donors. The mean interval between IBD diagnosis and BD was 1.7 days (standard deviation [SD] 2.0 days) using IBD-FOUR and 2.0 days (SD 1.96 days) using IBD-GCS. Both FOUR and GCS had 100% sensitivity and low specificity (FOUR: 53.8%; GCS: 50.0%) in predicting BD. Conclusions: Daily IBD evaluation in the ICU is feasible using FOUR and GCS with the assessment of brain stem reflexes. Both scales had 100% sensitivity in predicting IBD, but FOUR may be preferable since it incorporates the pupillary, corneal, and cough reflexes and spontaneous breathing that are easily assessed in the ICU.

The IN-PANCIA Study: Clinical Evaluation of Gastrointestinal Dysfunction and Failure, Multiple Organ Failure, and Levels of Citrulline in Critically Ill Patients

Purpose: Gastrointestinal dysfunction and failure (GID and GIF) in critically ill patients are a common, relevant, and underestimated complications in ICU patients. The aims of this study were (1) to determine plasmatic levels of citrulline, glutamine, and arginine as markers of GID/GIF in critically ill patients with or without GID/GIF with or without multiple organ failure (MOF) and (2) to assess the role of intra-abdominal hypertension in these patient groups. Materials and Methods: This is a 1-year, monocentric (Italian hospital), prospective observational study. Inclusion criteria were adult patients with GID/GIF, with or without MOF. The GIF score was daily evaluated in 39 critically ill patients. Amino acids were measured at the time of GID or GIF. Results: We enrolled 39 patients. Nine patients developed GID and 7 GIF; 6 of patients with GID/GIF developed MOF. Citrulline was lower (P < .001) in patients with GID/GIF (11.3 [4.4] µmol/L), compared to patients without GID/GIF (22.4 [6.8] µmol/L); likewise, glutamine was lower in patients with GID/GIF, whereas arginine was nonstatistically different between the 2 groups. Intra-abdominal pressure was higher in patients affected by MOF (13.0 [2.2] mm Hg) than in patients with GIF/GID without MOF (9.6 [2.6] mm Hg) and compared to patients without GID/GIF (7.2 [2.1] mm Hg). Conclusions: Both GID and GIF in critically ill patients are associated with low levels of citrulline and glutamine, which could be considered as markers of small bowel dysfunction. The higher the GIF score, the lower the citrulline levels. Patients affected by MOF had higher levels of intra-abdominal pressure.