Marco Brizzi

Neurological prognostication after cardiac arrest—Recommendations from the Swedish Resuscitation Council

Cardiopulmonary resuscitation is started in 5000 victims of out-of-hospital cardiac arrest in Sweden each year and the survival rate is approximately 10%. The subsequent development of a global ischaemic brain injury is the major determinant of the neurological prognosis for those patients who reach the hospital alive. Induced hypothermia is a recommended treatment after cardiac arrest and has been implemented in most Swedish hospitals. Recent studies indicate that induced hypothermia may affect neurological prognostication and previous international recommendations are therefore no longer valid when hypothermia is applied. An expert group from the Swedish Resuscitation Council has reviewed the literature and made recommendations taking into account the effects of induced hypothermia and concomitant sedation. A delayed neurological evaluation at 72 h after rewarming is recommended for hypothermia treated patients. This evaluation should be based on several independent methods and the possibility of lingering pharmacological effects should be considered.

Swirl sign in intracerebral haemorrhage: definition, prevalence, reliability and prognostic value

BackgroundSwirl sign has previously been described in epidural hematomas as areas of low attenuation, radiolucency or irregular density. The aims of this study were to describe swirl sign in ICH, study its prevalence, study the reliability of the subjective evaluation on computed tomography (CT), and to explore its prognostic value.MethodsCTs of 203 patients with ICH were retrospectively evaluated for the presence of swirl sign. Association between swirl sign and different clinical and radiological variables was studied.ResultsInter- and intraobserver agreement with regard to the occurrence of swirl sign was substantial (К 0.80) and almost perfect (К 0.87), respectively. Swirl sign was found in 30% of the study population. 61% of patients with swirl sign were dead at one month compared with 21% of those with no swirl sign (p < 0.001). Only 19% of patients with swirl sign exhibited favorable outcome at three months compared with 53% of those with no swirl sign (p < 0.001). Patients with swirl sign exhibited larger ICHs with average ICH-volume 52 ± 50 ml (median 42 ml) compared with 15 ± 25 ml (median 6) in patients whose CT did not show swirl sign (p < 0.001). Swirl sign was independent predictor of death at one month (p = 0.03; adjusted odds ratio 2.6, 95% CI 1.1 – 6), and functional outcome at three months (p = 0.045; adjusted odds ratio 2.6, 95% CI 1.02 – 6.5).ConclusionsAs swirl sign showed to be an ominous sign, we recommend identification of this sign in cases of ICHs.

Hyperdense middle cerebral artery sign is an ominous prognostic marker despite optimal workflow.

Abul‐Kasim K, Brizzi M, Petersson J. Hyperdense middle cerebral artery sign is an ominous prognostic marker despite optimal workflow.
Acta Neurol Scand: DOI: 2010: 122: 132–139.
© 2009 The Authors Journal compilation

Feasibility of endovascular and surface cooling strategies in acute stroke

Therapeutic hypothermia (TH) is a promising treatment of stroke, but limited data are available regarding the safety and effectiveness of cooling methodology. We investigated the safety of TH and compared the cooling capacity of two widely used cooling strategies – endovascular and surface cooling.

Early do-not-resuscitate orders in intracerebral haemorrhage; frequency and predictive value for death and functional outcome. A retrospective cohort study

IntroductionIn former studies from North America early Do-Not–Resuscitate orders (DNR orders) in patients with intracerebral haemorrhage (ICH) had negative prognostic impact on mortality. The influence of DNR orders on functional outcome and whether DNR orders are grounded on relevant patient characteristics is unknown. We aimed to determine the frequency and predictive factors of DNR-orders and its association to prognosis, in ICH patients, in Scandinavia.MethodsIn 197 consecutive ICH patients admitted to Skåne University Hospital, Malmö, Sweden, between January 2007 and June 2009, information of the presence of DNR orders within 48 hours, clinical and radiological characteristics was retrieved by review of patient medical journal and computed tomography scans. Determinants of DNR-orders, one-month case fatality and bad functional outcome (modified Rankin Scale, grade 4–6) were assessed by logistic regression analysis.ResultsDNR orders were made in 41% of the cases. After adjustment for confounding factors, age ≥ 75 years (Odds Ratio (95% confidence interval) 4.2(1.8-9.6)), former stroke (5.1(1.9-3.1)), Reaction Level Scale grade 2–3 and 4 (7.0(2.8-17.5) and (4.1(1.2-13.5), respectively) and intraventricular haemorrhage (3.8(1.6-9.4)) were independent determinants of early DNR orders. Independent predictors of one-month case fatality was age ≥ 75 years (3.7(1.4-9.6)) volume ≥ 30 ml (3.5(1.3-9.6)) and DNR orders (3.5(1.5-8.6)). Seizure (6.0(1.04-34.2) and brain stem hemorrhage (8.0(1.1-58.4)) were related to bad functional outcome, whereas early DNR order was not (3.5(0.99-12.7)).ConclusionsWell known prognostic factors are determinants for DNR orders, however DNR orders are independently related to one-month case fatality. In addition to improvements of the local routines, we welcome a change of attitude with an enhanced awareness of the definition of, and a more careful approach with respect to DNR orders.

Hyperdense middle cerebral artery sign in multidetector computed tomography: Definition, occurrence, and reliability analysis.

BACKGROUND The hyperdense middle cerebral artery sign (HMCAS) is one of the early changes seen on the computed tomography in acute ischemic stroke of MCA territory. AIMS To evaluate the reliability of subjective evaluation of HMCAS on CT performed at multidetector CT (MDCT) and evaluated in the Picture Archiving Communication Systems, to define objective criteria for HMCAS and to find out if there are any predictors for the occurrence of HMCAS. MATERIALS AND METHODS CTs of 121 consecutive patients (mean age of 70 years) treated with thrombolytic therapy were retrospectively evaluated by two neuroradiologists both subjectively and objectively with respect to HMCAS. RESULTS HMCAS was subjectively found in 32% of study population. The interobserver and intraobserver agreement were substantial (K value of 0.69 and 0.80, respectively) and increased to almost perfect (K value of 0.86) when the reader provided with clinical information. The HMCAS was found twice as often in male patients. Patients with HMCAS were three years younger than those whose baseline CT did not show HMCAS. A 100% sensitivity achieved when objective criteria were defined as combination of MCA attenuation >or= 46 HU and MCA ratio > 1.2 (using oval ROIs) and MCA attenuation >or= 50 HU and MCA ratio of > 1.4 (using pixel sized ROIs). CONCLUSION Performing CT examinations on MDCT and assessment of the images in PACS might have contributed to improvement of the reliability of evaluating HMCAS on CT by enabling an objective evaluation of this sign with measurements of attenuation value in the course of MCA using oval or pixel sized ROIs as well as estimation of MCA ratio.

Secondary Prevention and Health Promotion after Stroke: Can It Be Enhanced?

The aim was to study if health outcome and secondary prevention were satisfactory 1 year after stroke and if nurse-led interventions 3 months after stroke could have impact. Design was a randomized controlled open trial in a 1-year population. Primary outcome was health status 1 year after stroke. One month after stroke, survivors were randomized into intervention group (IG) with follow-up by a specialist nurse (SN) after 3 months (n = 232), and control group (CG) with standard care (n = 227), all to be followed up 1 year after stroke. At the first follow-up, patients graded their health, replied to the EuroQol-5 Dimensions (EQ-5D) health outcome questions, health problems were assessed, and supportive counseling was provided in the IG. Health problems requiring medical interventions were primarily referred to a general practitioner (GP). One year after stroke, 391 survivors were followed up. Systolic blood pressure (BP) had decreased in IG (n = 194) from median 140 to 135 (P = .05), but about half were above the limit 139 in both groups. A larger proportion (22%) had systolic BP >155 in the CG (n = 197) than in the IG (14%; P = .05). In the IG, 62% needed referrals compared with the 75% in the CG (P = .009). Forty percent in the IG and 52.5% in the CG (P = .04) reported anxiety/depression. In the IG, 75% and 67% in the CG rated their general health as fairly good or very good (P = .05). Although nurse-led interventions could have some effect, the results were not optimal. A more powerful strategy could be closer collaboration between the SN and a stroke clinician, before referring to primary care.