Neurocritical care
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Editorial Review Historical Article
The Origin of the Burst-Suppression Paradigm in Treatment of Status Epilepticus.
After electroencephalography (EEG) was introduced in hospitals, early literature recognized burst-suppression pattern (BSP) as a distinctive EEG pattern characterized by intermittent high-power oscillations alternating with isoelectric periods in coma and epileptic encephalopathies of childhood or the pattern could be induced by general anesthesia and hypothermia. The term was introduced by Swank and Watson in 1949 but was initially described by Derbyshire et al. in 1936 in their study about the anesthetic effects of tribromoethanol. Once the EEG/BSP pattern emerged in the literature as therapeutic goal in refractory status epilepticus, researchers began exploring whether the depth of EEG suppression correlated with improved seizure control and clinical outcomes. We can conclude that, from a historical perspective, the evidence to suppress the brain to a BSP when treating status epilepticus is inconclusive.
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How continuous cerebral autoregulation (CCA) knowledge should be optimally gained and interpreted is still an active area of research and refinement. We now experience a unique situation of having indices clinically available before definitive evidence of benefit or practice guidelines, in a moment when high rates of institutional variability exist both in the application of monitoring as well as in monitoring-guided treatments. Responses from 47 international clinicians, experts in this field, were collected with polling and discussion of the results. ⋯ There was nearly universal interest to participate in an RCT, with agreement that the research community must together determine end points and interventions to reduce wasted effort and time, and that investigations should include the following: the most appropriate way of inclusion of CCA into the clinical workflow; whether CCA-guided interventions should be prophylactic, proactive; or reactive; and whether a CCA-centric (unimodal) or a multimodal monitoring-integrated tiered therapy approach should be adopted. Pediatric and neonatal populations were highlighted as having urgent need and even more plausibility than adults. On the whole, the initiative was enthusiastically embraced by the experts, with the general feeling that a strong push should be now made by the community to convert the plausible benefits of CCA monitoring, already implemented in some centers, into a more standardized and RCT-validated clinical reality.
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Multicenter Study
Long-Term Outcomes Following Freehand Minimally Invasive Aspiration for Deep Supratentorial Intracerebral Hemorrhage: A Multicenter Cohort Study.
The aim of this study was to compare the therapeutic effects of non-navigated freehand minimally invasive aspiration and conservative medical care in patients with deep supratentorial intracerebral hemorrhage (ICH). ⋯ For deep supratentorial ICH, non-navigated freehand minimally invasive aspiration was safe and reduced short-term mortality but did not effectively improve long-term functional outcomes.
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The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.
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Multicenter Study
Enhancing European Management of Analgesia, Sedation, and Delirium: A Multinational, Prospective, Interventional Before-After Trial.
The objective of this study was to analyze the impact of a structured educational intervention on the implementation of guideline-recommended pain, agitation, and delirium (PAD) assessment. ⋯ In routine care, many patients were not assessed for PAD. Assessment rates increased significantly 1 year after the intervention. Clinical trial registration ClinicalTrials.gov: NCT03553719.