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Pattern of brain injury in the acute

Critical Care2013, 17:R204

Andrea Polito (andreaF d i Ei h ld (f

Critical Care

mailto:andrea.polito@rpc.aphp.frmailto:feichwald@yahoo.frmailto:feichwald@yahoo.frmailto:andrea.polito@rpc.aphp.fr

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PATTERN OF BRAIN INJURY IN THE ACUT

Andrea Polito1; Frdric Eischwald

2; Anne-Laure L

Annane1; Fabrice Chrtien

5; Robert D Steve

1

General Intensive Care Medicine Assistance Publique H

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Abstract

Background: Sepsis-associated brain dysfunctio

(leucoencephalopathy) and ischemic stroke. Our o

lesions in septic shock patients requiring magn

l i l h

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Introduction

Brain dysfunction is a frequent and severe complic

patients [1, 2] and is associated with increased mort

5]. It is clinically characterized by an acute alter

delirium and less frequently by seizures or focal

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Materials and methods

Patients and settings

This was a prospective observational study that wa

intensive care unit (ICU) of an university teaching

France). Patients were enrolled at our institution fro

li ibl f i l i if th t th f ll i

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tendon reflexes and plantar reflexes. Coma was def

three days of discontinuation of sedation in previou

as generalized or focal (face or limb) tonic or clon

or eyelid twitching. Any lateralized deficit was cons

B i M ti R I i

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In patients with ischemic stroke, a standard ECG, a

performed. In patients with arrhythmias, continuo

Health Care, Ultraview SL, Washington, USA

classification, patients were eventually classified

atherosclerosis (thrombo-embolic) episode [16]. A

d li i i d t EEG i ti E

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were represented by ICU mortality, hospital and

ventilation and GOS at 6 months (dichotomized at

Statistical Analysis

STATA software, Version 111 data analysis and st

T ) d f t ti ti l l i C ti

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Results

From November 2005 to June 2012, 170 patients

acute brain dysfunction; of those, 71 (42%) patients

median time delay from acute brain dysfunction of

enrolled because of patients death before MRI (n

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severity of septic shock and hemodynamic failur

subgroups (Table 2) as well as pathogens, v

prothrombin time, haemoglobin and lactate levels

were more frequently associated with ischemic

underwent an EEG, four had mixed brain lesions an

f t i ti t ith i l t d i h i t k

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Discussion

Our observational study shows that, in septic sh

brain MRI can reveal leukoencephalopathy or isch

ICU mortality and increased odds of having GOS>

ischemic stroke (31%) is higher than previously rep

[8] Thi di b l i d b th f t

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More sophisticated analysis including plasma cyt

warranted for future studies.

Finally, we found that MRI is normal in 52% of o

with those obtained by Suchyta et al in critically

l i i ti ti t i ht b b d th l

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strength, use of spectroscopy and of diffusion te

smaller ischemic lesions or other anatomical or neu

A larger cohort of patients would allow a more accu

brain lesion and their respective risk factors. Yet av

scant, often retrospective, single centre and have in

diffi lti t f h l ti i ti

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2. Ischemic stroke is associated with increasedbiological DIC.

3. Severity and type of neuroradiological lesion

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Abbreviations

ADC: Apparent Diffusion Coefficient; ATICE: ABBB: blood-brain barrier; CAM-ICU: Confusi

disseminated intravascular coagulation; DW

electrocardiogram; EEG: electroencephalography

attenuated inversion recovery; GCS: Glasgow Com

I i C U i MBP bl d

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References

1. Iacobone E, Bailly-Salin J, Polito A, Fr

associated encephalopathy and its differe

336.

2. Sprung CL, Peduzzi PN, Shatney CH, Sche

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Marshall J, Ranieri M, Ramsay G, Sevran

Zimmerman JL, Vincent JL: Surviving Se

management of severe sepsis and septic sh

10. Siami S, Bailly-Salin J, Polito A, Porcher R

V, Boucly C, Carlier R, Annane D, Sharshar

l d i h h f i h

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16. Adams HP, Jr., Bendixen BH, Kappelle LJ,

Classification of subtype of acute ischem

clinical trial. TOAST. Trial of Org 10172

41.

17. Synek VM: Prognostically important E

i h l hi i d l C

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25. Walkey AJ, Wiener RS, Ghobrial JM, C

mortality associated with new-onset atr

severe sepsis.JAMA 2011, 306:2248-2254.

26. Lee JY, Insel P, Mackin RS, Schuff N, Ch

MW: Different associations of white matte

l

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LEGEND OF FIGURES

Figure 1 Flow chart. Other neurological di

cerebrovascular disease, brain infection and end

presence of metallic devices.

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Table 1 - Main characteristics between admission, i

VARIABLES ADMISSION

Women

Age (years)

Cardiovascular risk factors (%)

Atrial fibrillation (%)

Blood culture (%)

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Abbreviations

SAPS-II: New Simplified Acute Physiology ScorSepsis-related Organ Failure Assessment; PaO2: pa

oxygen saturation; MBP: mean blood pressure; DI

intensive care unit; GOS: Glasgow Outcome Scale

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Table 2 Comparison of demographic characteris

with normal MRI, isolated ischemic stroke and leuc

Total

63

Normal

37

Demographics

Age (years) 64 (55-75) 61 (48-78)

Women 25 (40) 12 (32)

Cardiovascular risk 37 (59) 19 (51)

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Table 3 Comparison of neurological and electroen

normal MRI, isolated leukoencephalopathy or isola

Clinical features Total

63

Normal

37

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Figure 2

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Figure 3

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Figure 4