Publications by authors named "David J Roh"

28 Publications

  • Page 1 of 1

Dynamic Intracranial Pressure Waveform Morphology Predicts Ventriculitis.

Neurocrit Care 2021 Jul 30. Epub 2021 Jul 30.

Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8 Milstein - 300 Center, New York, NY, USA.

Background: Intracranial pressure waveform morphology reflects compliance, which can be decreased by ventriculitis. We investigated whether morphologic analysis of intracranial pressure dynamics predicts the onset of ventriculitis.

Methods: Ventriculitis was defined as culture or Gram stain positive cerebrospinal fluid, warranting treatment. We developed a pipeline to automatically isolate segments of intracranial pressure waveforms from extraventricular catheters, extract dominant pulses, and obtain morphologically similar groupings. We used a previously validated clinician-supervised active learning paradigm to identify metaclusters of triphasic, single-peak, or artifactual peaks. Metacluster distributions were concatenated with temperature and routine blood laboratory values to create feature vectors. A L2-regularized logistic regression classifier was trained to distinguish patients with ventriculitis from matched controls, and the discriminative performance using area under receiver operating characteristic curve with bootstrapping cross-validation was reported.

Results: Fifty-eight patients were included for analysis. Twenty-seven patients with ventriculitis from two centers were identified. Thirty-one patients with catheters but without ventriculitis were selected as matched controls based on age, sex, and primary diagnosis. There were 1590 h of segmented data, including 396,130 dominant pulses in patients with ventriculitis and 557,435 pulses in patients without ventriculitis. There were significant differences in metacluster distribution comparing before culture-positivity versus during culture-positivity (p < 0.001) and after culture-positivity (p < 0.001). The classifier demonstrated good discrimination with median area under receiver operating characteristic 0.70 (interquartile range 0.55-0.80). There were 1.5 true alerts (ventriculitis detected) for every false alert.

Conclusions: Intracranial pressure waveform morphology analysis can classify ventriculitis without cerebrospinal fluid sampling.
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http://dx.doi.org/10.1007/s12028-021-01303-3DOI Listing
July 2021

Dynamic Detection of Delayed Cerebral Ischemia: A Study in 3 Centers.

Stroke 2021 Apr 18;52(4):1370-1379. Epub 2021 Feb 18.

Department of Neurology (M.M., K.T., H.C., D.J.R., S.A., A.V., A.B., J.C., S.P.), Columbia University Irving Medical Center, New York.

Background And Purpose: Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage negatively impacts long-term recovery but is often detected too late to prevent damage. We aim to develop hourly risk scores using routinely collected clinical data to detect DCI.

Methods: A DCI classification model was trained using vital sign measurements (heart rate, blood pressure, respiratory rate, and oxygen saturation) and demographics routinely collected for clinical care. Twenty-two time-varying physiological measures were computed including mean, SD, and cross-correlation of heart rate time series with each of the other vitals. Classification was achieved using an ensemble approach with L2-regularized logistic regression, random forest, and support vector machines models. Classifier performance was determined by area under the receiver operating characteristic curves and confusion matrices. Hourly DCI risk scores were generated as the posterior probability at time using the Ensemble classifier on cohorts recruited at 2 external institutions (n=38 and 40).

Results: Three hundred ten patients were included in the training model (median, 54 years old [interquartile range, 45-65]; 80.2% women, 28.4% Hunt and Hess scale 4-5, 38.7% Modified Fisher Scale 3-4); 101 (33%) developed DCI with a median onset day 6 (interquartile range, 5-8). Classification accuracy before DCI onset was 0.83 (interquartile range, 0.76-0.83) area under the receiver operating characteristic curve. Risk scores applied to external institution datasets correctly predicted 64% and 91% of DCI events as early as 12 hours before clinical detection, with 2.7 and 1.6 true alerts for every false alert.

Conclusions: An hourly risk score for DCI derived from routine vital signs may have the potential to alert clinicians to DCI, which could reduce neurological injury.
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http://dx.doi.org/10.1161/STROKEAHA.120.032546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8247633PMC
April 2021

Prior antiplatelet therapy and haematoma expansion after primary intracerebral haemorrhage: an individual patient-level analysis of CLEAR III, MISTIE III and VISTA-ICH.

J Neurol Neurosurg Psychiatry 2020 Oct 26. Epub 2020 Oct 26.

Departments of Neurology, Neurosurgery, and Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

Objective: To evaluate the relationship between prior antiplatelet therapy (APT) and outcomes after primary intracerebral haemorrhage (ICH), and assess if it varies by haematoma location.

Methods: We pooled individual patient data from the Virtual International Stroke Trials Archive-ICH trials dataset, Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase III trial. The exposure was APT preceding ICH diagnosis. The primary outcome was haematoma expansion at 72 hours. Secondary outcomes were admission haematoma volume, all-cause mortality, death or major disability (modified Rankin Scale (mRS) score ≥4) and shift in mRS distribution. Mixed-effects models were used to assess the relationship between APT and outcomes. Secondary analyses were stratified by ICH location and study cohort.

Results: Among 1420 patients with ICH, there were 782 (55.1%) lobar and 596 (42.0%) deep haemorrhages. APT was reported in 284 (20.0%) patients. In adjusted regression models, prior APT was not associated with haematoma expansion (OR, 0.97; 95% CI 0.60 to 1.57), major disability or death (OR, 1.05; 95% CI 0.61 to 1.63), all-cause mortality (OR, 0.89; 95% CI 0.47 to 1.85), admission haematoma volume (beta, -0.17; SE, 0.09; p=0.07) and shift in mRS (p=0.43). In secondary analyses, APT was associated with admission haematoma volume in lobar ICH (beta, 0.25; SE, 0.12; p=0.03), but there was no relationship with other ICH outcomes when stratified by haematoma location or study cohort.

Conclusions: In a large heterogeneous cohort of patients with ICH, prior APT was not associated with haematoma expansion or functional outcomes after ICH, regardless of haematoma location. APT was associated with admission haematoma volumes in lobar ICH.
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http://dx.doi.org/10.1136/jnnp-2020-323458DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8071838PMC
October 2020

Hypercoagulable viscoelastic blood clot characteristics in critically ill coronavirus disease 2019 patients and associations with thrombotic complications.

J Trauma Acute Care Surg 2021 01;90(1):e7-e12

From the Division of Critical Care and Hospitalist Neurology (D.J.R., H.K., A.B., S.A., S.P., J.C.), Department of Neurology, New York-Presbyterian Hospital and Vagelos College of Physicians and Surgeons, Columbia University; Department of Neurology (A.B.), Vagelos College of Physicians and Surgeons, Columbia University; Department of Neurological Surgery (N.Y., E.S.C.), New York-Presbyterian Hospital and Vagelos College of Physicians and Surgeons, Columbia University; and Department of Anesthesiology (K.E., G.W.), Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York.

Background: Critically ill coronavirus disease 2019 (COVID-19) patients have frequent thrombotic complications and laboratory evidence of hypercoagulability. The relationship of coagulation tests and thrombosis requires investigation to identify best diagnostic and treatment approaches. We assessed for hypercoagulable characteristics in critically ill COVID-19 patients using rotational thromboelastometry (ROTEM) and explored relationships of D-dimer and ROTEM measurements with thrombotic complications.

Methods: Critically ill adult COVID-19 patients receiving ROTEM testing between March and April 2020 were analyzed. Patients receiving therapeutic anticoagulation before ROTEM were excluded. Rotational thromboelastometry measurements from COVID-19 patients were compared with non-COVID-19 patients matched by age, sex, and body mass index. Intergroup differences in ROTEM measurements were assessed using t tests. Correlations of D-dimer levels to ROTEM measurements were assessed in COVID-19 patients who had available concurrent testing. Intergroup differences of D-dimer and ROTEM measurements were explored in COVID-19 patients with and without thrombosis.

Results: Of 30 COVID-19 patients receiving ROTEM, we identified hypercoagulability from elevated fibrinogen compared with non-COVID-19 patients (fibrinogen assay maximum clot firmness [MCF], 47 ± 13 mm vs. 20 ± 7 mm; mean intergroup difference, 27.4 mm; 95% confidence interval [CI], 22.1-32.7 mm; p < 0.0001). In our COVID-19 cohort, thrombotic complications were identified in 33%. In COVID-19 patients developing thrombotic complications, we identified higher D-dimer levels (17.5 ± 4.3 μg/mL vs. 8.0 ± 6.3 μg/mL; mean difference, 9.5 μg/mL; 95% CI, 13.9-5.1; p < 0.0001) but lower fibrinogen assay MCF (39.7 ± 10.8 mm vs. 50.1 ± 12.0 mm; mean difference, -11.2 mm; 95% CI, -2.1 to -20.2; p = 0.02) compared with patients without thrombosis. We identified negative correlations of D-dimer levels and ROTEM MCF in these patients (r = -0.61; p = 0.001).

Conclusion: We identified elevated D-dimer levels and hypercoagulable blood clot characteristics from increased fibrinogen on ROTEM testing in critically ill COVID-19 patients. However, we identified lower, albeit still hypercoagulable, ROTEM measurements of fibrinogen in COVID-19 patients with thrombotic complications compared with those without. Further work is required to externally validate these findings and to investigate the mechanistic drivers for these relationships to identify best diagnostic and treatment approaches for these patients.

Level Of Evidence: Epidemiologic, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002963DOI Listing
January 2021

Red Blood Cell Transfusions and Outcomes After Intracerebral Hemorrhage.

J Stroke Cerebrovasc Dis 2020 Dec 26;29(12):105317. Epub 2020 Sep 26.

Clinical and Translational Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, NY, United States. Electronic address:

Background: Low red blood cell (RBC) levels are associated with worse intracerebral hemorrhage (ICH) outcomes. However, relationships of RBC transfusions on ICH outcomes are unclear given the overlap of RBC transfusion, comorbidities, and disease severity. We investigated RBC transfusion relationships on ICH outcomes while accounting for comorbidities and disease severity.

Methods: ICH hospitalizations between 2002 and 2011 and RBC transfusion exposure were identified from the Nationwide Inpatient Sample using ICD-9-CM codes. Logistic regression was used to study the relationship between RBC transfusion on outcomes after adjusting for demographics, baseline comorbidities, and markers of disease severity. Additional sensitivity analyses stratified by comorbidity burden and disease severity were performed.

Results: Of 597,046 ICH hospitalizations, RBC transfusions were administered in 22,904 (4%). RBC transfusion was associated with higher odds of in-hospital mortality (adjusted OR: 1.22 [95%CI: 1.10-1.35]). In sensitivity analyses, RBC transfusions resulted in poor outcomes regardless of the comorbidity burden, but attenuation in this relationship was notable with lower comorbidities (adjusted OR 1.43 [95%CI: 1.34-1.51] vs 1.18 [95%CI: 1.10-1.29]). There were no associations of RBC transfusions with poor outcomes in hospitalizations without mechanical ventilation (adjusted OR 0.88 [95%CI: 0.83-1.13]) and in cases requiring ventriculostomy drains (adjusted OR 1.05 [95%CI: 0.97-1.10]).

Conclusions: In a large, nationally representative sample, RBC transfusion was associated with poor ICH outcomes. However, there were variations in this relationship based on comorbidities and disease severity. Additional prospective studies are required to assess direct risks and benefits from RBC transfusions in ICH.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686150PMC
December 2020

Hyperarousal Symptoms in Survivors of Cardiac Arrest Are Associated With 13 Month Risk of Major Adverse Cardiovascular Events and All-Cause Mortality.

Ann Behav Med 2020 05;54(6):413-422

Department of Neurology, Columbia University Medical Center, New York, NY, USA.

Background: Key dimensions of cardiac arrest-induced posttraumatic stress disorder (PTSD) symptoms include reexperiencing, avoidance, numbing, and hyperarousal. It remains unknown which dimensions are most predictive of outcome.

Purpose: To determine which dimensions of cardiac arrest-induced PTSD are predictive of clinical outcome within 13 months posthospital discharge.

Methods: PTSD symptoms were assessed in survivors of cardiac arrest who were able to complete psychological screening measures at hospital discharge via the PTSD Checklist-Specific scale, which queries for 17 symptoms using five levels of severity. Responses on items for each symptom dimension of the four-factor numbing model (reexperiencing, avoidance, numbing, and hyperarousal) were converted to Z-scores and treated as continuous predictors. The combined primary endpoint was all-cause mortality (ACM) or major adverse cardiovascular events (MACE; hospitalization for myocardial infarction, unstable angina, heart failure, emergency coronary revascularization, or urgent defibrillator/pacemaker placements) within 13 months postdischarge. Four bivariate Cox proportional hazards survival models evaluated associations between individual symptom dimensions and ACM/MACE. A multivariable model then evaluated whether significant bivariate predictors remained independent predictors of the primary outcome after adjusting for age, sex, comorbidities, premorbid psychiatric diagnoses, and initial cardiac rhythm.

Results: A total of 114 patients (59.6% men, 52.6% white, mean age: 54.6 ± 13 years) were included. In bivariate analyses, only hyperarousal was significantly associated with ACM/MACE. In a fully adjusted model, 1 standard deviation increase in hyperarousal symptoms corresponded to a two-times increased risk of experiencing ACM/MACE.

Conclusions: Greater level of hyperarousal symptoms was associated with a higher risk of ACM/MACE within 13 months postcardiac arrest. This initial evidence should be further investigated in a larger sample.
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http://dx.doi.org/10.1093/abm/kaz058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7246258PMC
May 2020

Liver Fibrosis Indices and Outcomes After Primary Intracerebral Hemorrhage.

Stroke 2020 03 7;51(3):830-837. Epub 2020 Jan 7.

From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., H.K., B.B.N., C.I., A.E.M., S.B.M.), Weill Cornell Medicine, New York, NY.

Background and Purpose- Cirrhosis-clinically overt, advanced liver disease-is associated with an increased risk of hemorrhagic stroke and poor stroke outcomes. We sought to investigate whether subclinical liver disease, specifically liver fibrosis, is associated with clinical and radiological outcomes in patients with primary intracerebral hemorrhage. Methods- We performed a retrospective cohort study using data from the Virtual International Stroke Trials Archive-Intracerebral Hemorrhage. We included adult patients with primary intracerebral hemorrhage presenting within 6 hours of symptom onset. We calculated 3 validated fibrosis indices-Aspartate Aminotransferase-Platelet Ratio Index, Fibrosis-4 score, and Nonalcoholic Fatty Liver Disease Fibrosis Score-and modeled them as continuous exposure variables. Primary outcomes were admission hematoma volume and hematoma expansion. Secondary outcomes were mortality, and the composite of major disability or death, at 90 days. We used linear and logistic regression models adjusted for previously established risk factors. Results- Among 432 patients with intracerebral hemorrhage, the mean Aspartate Aminotransferase-Platelet Ratio Index, Fibrosis-4, and Nonalcoholic Fatty Liver Disease Fibrosis Score values on admission reflected intermediate probabilities of fibrosis, whereas standard hepatic assays and coagulation parameters were largely normal. After adjusting for potential confounders, Aspartate Aminotransferase-Platelet Ratio Index was associated with hematoma volume (β, 0.20 [95% CI, 0.04-0.36]), hematoma expansion (odds ratio, 1.6 [95% CI, 1.1-2.3]), and mortality (odds ratio, 1.8 [95% CI, 1.1-2.7]). Fibrosis-4 was also associated with hematoma volume (β, 0.27 [95% CI, 0.07-0.47]), hematoma expansion (odds ratio, 1.9 [95% CI, 1.2-3.0]), and mortality (odds ratio, 2.0 [95% CI, 1.1-3.6]). Nonalcoholic Fatty Liver Disease Fibrosis Score was not associated with any outcome. Indices were not associated with the composite of major disability or death. Conclusions- In patients with largely normal liver chemistries, 2 liver fibrosis indices were associated with admission hematoma volume, hematoma expansion, and mortality after intracerebral hemorrhage.
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http://dx.doi.org/10.1161/STROKEAHA.119.028161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7048169PMC
March 2020

Antiplatelet Therapy After Spontaneous Intracerebral Hemorrhage and Functional Outcomes.

Stroke 2019 11 20;50(11):3057-3063. Epub 2019 Sep 20.

Henry and Allison McCance Center for Brain Health (A.B., J.R.), Massachusetts General Hospital, Boston, MA.

Background and Purpose- Observational data suggest that antiplatelet therapy after intracerebral hemorrhage (ICH) alleviates thromboembolic risk without increasing the risk of recurrent ICH. Given the paucity of data on the relationship between antiplatelet therapy after ICH and functional outcomes, we aimed to study this association in a multicenter cohort. Methods- We meta-analyzed data from (1) the Massachusetts General Hospital ICH registry (n=1854), (2) the Virtual International Stroke Trials Archive database (n=762), and (3) the Yale stroke registry (n=185). Our exposure was antiplatelet therapy after ICH, which was modeled as a time-varying covariate. Our primary outcomes were all-cause mortality and a composite of major disability or death (modified Rankin Scale score 4-6). We used Cox proportional regression analyses to estimate the hazard ratio of death or poor functional outcome as a function of antiplatelet therapy and random-effects meta-analysis to pool the estimated HRs across studies. Additional analyses stratified by hematoma location (lobar and deep ICH) were performed. Results- We included a total of 2801 ICH patients, of whom 288 (10.3%) were started on antiplatelet medications after ICH. Median times to antiplatelet therapy ranged from 7 to 39 days. Antiplatelet therapy after ICH was not associated with mortality (hazard ratio, 0.85; 95% CI, 0.66-1.09), or death or major disability (hazard ratio, 0.83; 95% CI, 0.59-1.16) compared with patients not started on antiplatelet therapy. Similar results were obtained in additional analyses stratified by hematoma location. Conclusions- Antiplatelet therapy after ICH appeared safe and was not associated with all-cause mortality or functional outcome, regardless of hematoma location. Randomized clinical trials are needed to determine the effects and harms of antiplatelet therapy after ICH.
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http://dx.doi.org/10.1161/STROKEAHA.119.025972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6941441PMC
November 2019

Hyperemia in subarachnoid hemorrhage patients is associated with an increased risk of seizures.

J Cereb Blood Flow Metab 2020 06 11;40(6):1290-1299. Epub 2019 Jul 11.

Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA.

The association between impaired brain perfusion, cerebrovascular reactivity status and the risk of ictal events in patients with subarachnoid hemorrhage is unknown. We identified 13 subarachnoid hemorrhage (SAH) patients with seizures and 22 with ictal-interictal continuum (IIC), and compared multimodality physiological recordings to 38 similarly poor-grade SAH patients without ictal activity. We analyzed 10,179 cumulative minutes of seizure and 12,762 cumulative minutes of IIC. Cerebrovascular reactivity (PRx) was not different between subjects with seizures, IIC, or controls. Cerebral perfusion pressure (CPP) was higher in patients with seizures [99 ± 6.5,  = .005] and IIC [97 ± 8.5,  = .007] when compared to controls [89 ± 12.3]. DeltaCPP, defined as actual CPP minus optimal CPP (CPPopt), was also higher in the seizure group [8.3 ± 7.9,  = .0003] and IIC [8.1 ± 10.3,  = .0006] when compared to controls [-0.1 ± 5]. Time spent with supra-optimal CPP was higher in the seizure group [342 ± 213 min/day,  = .002] when compared to controls [154 ± 120 min/day]. In a temporal examination, a supra-optimal CPP preceded increased seizures and IIC in SAH patients, an hour before and continued to increase during the events [ < .0001].
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http://dx.doi.org/10.1177/0271678X19863028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238374PMC
June 2020

Low hemoglobin and hematoma expansion after intracerebral hemorrhage.

Neurology 2019 07 17;93(4):e372-e380. Epub 2019 Jun 17.

From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT.

Objective: Studies have independently shown associations of lower hemoglobin levels with larger admission intracerebral hemorrhage (ICH) volumes and worse outcomes. We investigated whether lower admission hemoglobin levels are associated with more hematoma expansion (HE) after ICH and whether this mediates lower hemoglobin levels' association with worse outcomes.

Methods: Consecutive patients enrolled between 2009 and 2016 to a single-center prospective ICH cohort study with admission hemoglobin and neuroimaging data to calculate HE (>33% or >6 mL) were evaluated. The association of admission hemoglobin levels with HE and poor clinical outcomes using modified Rankin Scale (mRS 4-6) were assessed using separate multivariable logistic regression models. Mediation analysis investigated causal associations among hemoglobin, HE, and outcome.

Results: Of 256 patients with ICH meeting inclusion criteria, 63 (25%) had HE. Lower hemoglobin levels were associated with increased odds of HE (odds ratio [OR] 0.80 per 1.0 g/dL change of hemoglobin; 95% confidence interval [CI] 0.67-0.97) after adjusting for previously identified covariates of HE (admission hematoma volume, antithrombotic medication use, symptom onset to admission CT time) and hemoglobin (age, sex). Lower hemoglobin was also associated with worse 3-month outcomes (OR 0.76 per 1.0 g/dL change of hemoglobin; 95% CI 0.62-0.94) after adjusting for ICH score. Mediation analysis revealed that associations of lower hemoglobin with poor outcomes were mediated by HE ( = 0.01).

Conclusions: Further work is required to replicate the associations of lower admission hemoglobin levels with increased odds of HE mediating worse outcomes after ICH. If confirmed, an investigation into whether hemoglobin levels can be a modifiable target of treatment to improve ICH outcomes may be warranted.
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http://dx.doi.org/10.1212/WNL.0000000000007820DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6669932PMC
July 2019

In-Hospital Survival and Neurological Recovery Among Patients Requiring Renal Replacement Therapy in Post-Cardiac Arrest Period.

Kidney Int Rep 2019 May 13;4(5):674-678. Epub 2019 Feb 13.

Department of Neurology, Columbia University Medical Center, New York, New York, USA.

Objectives: Acute kidney injury (AKI) is common after cardiac arrest (CA). Few data exist on survival and neurological outcomes measured at hospital discharge of patients with severe AKI requiring renal replacement therapy (RRT) within the first 72 hours (i.e., duration of post-CA syndrome).

Methods: Single-center, prospective, observation cohort of patients with in- or out-of-hospital CA who survived to intensive care unit admission and were considered for targeted temperature management between 2010 and 2016 were reviewed. After excluding preexisting RRT history, patients with new RRT requirements within the first 72 hours after CA were included. Primary outcome of survival and secondary outcome of good neurological recovery defined as cerebral performance category score of 1 to 2, were compared between patients with and without RRT. Within 24 hours of initiating RRT, illness severity, as measured by Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation-II, and Charlson Comorbidity Index, was compared between survivors and nonsurvivors.

Results: Of 524 patients, 65 (12.4%) had new RRT requirements within 72 hours. Survival rates and good neurological recovery at discharge were comparable between RRT and non-RRT groups (19 of 65 [29%] vs. 162 of 459 [35%],  = 0.3, and 8 of 19 [42%] vs. 73 of 162 [45%], respectively). Sixty-three percent (12 of 19) of survivors requiring RRT did not need dialysis on discharge. Among patients requiring RRT, prognostic factors, including illness severity scores and indications for RRT, did not differ between survivors and nonsurvivors.

Conclusions: Patients with severe AKI requiring RRT during the post-CA syndrome period were not associated with any significant reduction in survival or poor neurological recovery, compared with those without RRT. Among those requiring RRT, none of the known prognostic factors predicted survival.
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http://dx.doi.org/10.1016/j.ekir.2019.02.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506695PMC
May 2019

Dimensional structure of posttraumatic stress disorder symptoms after cardiac arrest.

J Affect Disord 2019 05 22;251:213-217. Epub 2019 Mar 22.

Department of Neurology, Columbia University Medical Center, New York, NY, United States. Electronic address:

Background: Considerable evidence suggests that posttraumatic stress disorder (PTSD) is a heterogeneous construct despite often being treated as a homogeneous diagnostic entity. PTSD in response to cardiac arrest is common and may differ from PTSD following other medical traumas. Most patients are amnesic from the cardiac event, and it is unclear if and how certain PTSD symptoms may manifest.

Methods: We examined the latent structure of PTSD symptoms in 104 consecutive cardiac arrest survivors who were admitted to Columbia University Medical Center. PTSD symptoms were assessed via the PTSD Checklist-Specific at hospital discharge. We performed a confirmatory factor analysis (CFA) to compare 4-factor dysphoria, 4-factor numbing, and 5-factor dysphoric arousal models of PTSD with our data.

Results: The CFA showed that each of the models had good fit. We chose the 4-factor numbing model (χ (113) = 151.59, p < .01, CFI = 0.94, RMSEA = 0.057, 90% CI: [0.032, 0.081]) as most representative of the data, after considering a between-factor correlation of 0.99 in the 5-factor dysphoric arousal model, and greater fit statistics than the 4-factor dysphoria model.

Limitations: Certain factors were defined by only two items. Additionally, PTSD was assessed at discharge (median = 21 days); those assessed before 30 days could be displaying symptoms of acute stress disorder.

Conclusions: Our findings suggest that PTSD symptoms after cardiac arrest are best represented by a 4-factor numbing model of PTSD. PTSD assessment and intervention efforts for cardiac arrest survivors should consider the underlying dimensions of PTSD.
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http://dx.doi.org/10.1016/j.jad.2019.03.064DOI Listing
May 2019

Cardiac Arrest and Subsequent Hospitalization-Induced Posttraumatic Stress Is Associated With 1-Year Risk of Major Adverse Cardiovascular Events and All-Cause Mortality.

Crit Care Med 2019 06;47(6):e502-e505

Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY.

Objectives: To compare 1-year all-cause mortality and major adverse cardiovascular events in cardiac arrest survivors with and without posttraumatic stress disorder symptomatology at hospital discharge.

Design: Prospective, observational cohort.

Setting: ICUs at a tertiary-care center.

Patients: Adults with return of spontaneous circulation after in-hospital or out-of-hospital cardiac arrest between September 2015 and September 2017. A consecutive sample of survivors with sufficient mental status to self-report cardiac arrest and subsequent hospitalization-induced posttraumatic stress disorder symptoms (cardiac arrest-induced posttraumatic stress symptomatology) at hospital discharge were included.

Interventions: None.

Measurements And Main Results: The combined primary endpoint was all-cause mortality or major adverse cardiovascular event-hospitalization for nonfatal myocardial infarction, unstable angina, congestive heart failure, emergency coronary revascularization, or urgent implantable cardio-defibrillators/permanent pacemaker placements within 12 months of discharge. An in-person posttraumatic stress disorder symptomatology was assessed at hospital discharge via the Posttraumatic Stress Disorder Checklist-Specific scale; a suggested diagnostic cutoff of 36 for specialized medical settings was adopted. Outcomes for patients meeting (vs not meeting) this cutoff were compared using Cox-hazard regression models. Of 114 included patients, 36 (31.6%) screened positive for cardiac arrest-induced posttraumatic stress symptomatology at discharge (median 21 d post cardiac arrest; interquartile range, 11-36). During the follow-up period (median = 12.4 mo; interquartile range, 10.2-13.5 mo), 10 (8.8%) died and 29 (25.4%) experienced a recurrent major adverse cardiovascular event: rehospitalizations due to myocardial infarction (n = 4; 13.8%), unstable angina (n = 8; 27.6%), congestive heart failure exacerbations (n = 4; 13.8%), emergency revascularizations (n = 5, 17.2%), and urgent implantable cardio-defibrillator/permanent pacemaker placements (n = 8; 27.6%). Cardiac arrest-induced posttraumatic stress symptomatology was associated with all-cause mortality/major adverse cardiovascular event in univariate (hazard ratio, 3.19; 95% CI, 1.7-6.0) and in models adjusted for age, sex, comorbidities, preexisting psychiatric condition, and nonshockable initial rhythm (hazard ratio, 3.1; 95% CI, 1.6-6.0).

Conclusions: Posttraumatic stress disorder symptomatology is common after cardiac arrest, and cardiac arrest-induced posttraumatic stress symptomatology was associated with significantly higher risk of death and cardiovascular events. Further studies are needed to better understand the underlying mechanisms.
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http://dx.doi.org/10.1097/CCM.0000000000003713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522295PMC
June 2019

Statins and perihemorrhagic edema in patients with spontaneous intracerebral hemorrhage.

Neurology 2019 04 6;92(18):e2145-e2149. Epub 2019 Feb 6.

From the Departments of Neurology (J.W., S.A., K.M., D.J.R., J.C., S.P.) and Neurosurgery (E.S.C.), Columbia University Medical Center, New York, NY; Department of Neurology (J.W.), Yale School of Medicine, New Haven, CT; and Departments of Neurology, Neurosurgery, and Radiology (F.A.-M.), Westchester Medical Center, New York Medical College, Valhalla.

Objective: To test the hypothesis that in patients with spontaneous intracerebral hemorrhage (ICH), perihemorrhagic edema to hematoma ratio (rPHE) on admission CT scan (aCT) is unaffected by home statin use when time from symptom onset to aCT is controlled for.

Methods: In a single-center prospective cohort of 176 consecutive ICH patients, 2 investigators independently determined hematoma and perihemorrhagic edema (PHE) volumes by using semiautomated validated software. rPHE were dichotomized at the median ratio (>0.75 vs ≤0.75). We used binary logistic regression to test for associations with rPHE.

Results: In patients using statins as home medication before hospital admission (n = 38) compared to patients without prior statin use (n = 138), median PHE volumes were 15.8 mL (interquartile range [IQR] 6.5-39.4) vs 10.8 mL (IQR 5.1-26.8), = 0.2. rPHE was 0.71 (IQR 0.56-1.0) vs 0.74 (IQR 0.52-1.0), = 0.79. In a binary logistic regression model, time of aCT relative to symptom onset (odds ratio [OR] 1.02, confidence interval [CI] 1.01-1.12, = 0.016) and presence of intraventricular hemorrhage on aCT (OR 0.40, CI 0.20-0.78, = 0.007) were but prior statin use was not (OR 1.17, CI 0.55-2.52, = 0.68) associated with rPHE.

Conclusion: Use of statins before hospital admission for ICH is not associated with reduced rPHE on admission CT. In future studies, imaging timing relative to ICH onset needs to be controlled for in order to avoid confounding.
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http://dx.doi.org/10.1212/WNL.0000000000006931DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6512886PMC
April 2019

The impact of psychological distress on long-term recovery perceptions in survivors of cardiac arrest.

J Crit Care 2019 04 18;50:227-233. Epub 2018 Dec 18.

Department of Neurology, Columbia University Medical Center, New York, NY, United States. Electronic address:

Purpose: To determine the association of depressive and PTSD symptoms with cardiac arrest survivors' long-term recovery perceptions, after accounting for cognitive status, functional independence, and medical comorbidities.

Methods: Perceived recovery of 78 cardiac arrest survivors at 6-months post-hospital discharge was assessed through the question, "Do you feel that you have made a complete recovery from your arrest?" Psychological symptoms were measured using the Center for Epidemiological Studies-Depression scale (CES-D) and the PTSD Checklist-Specific (PCLS). Logistic regression was utilized to assess the association between psychological symptoms with positive and negative recovery perceptions, adjusting for demographics, cognitive impairment, functional dependence, and medical comorbidities.

Results: At 6 months, 53% of patients (n = 41) had negative recovery perceptions. 32.1% (n = 25) of patients screened for depression and 28.2% (n = 22) for PTSD. Patients with higher CES-D scores were significantly more likely to have negative recovery perceptions in both unadjusted and adjusted analyses (OR: 1.10, 95% CI [1.03, 1.16], p < .01). PCL-S scores were significantly associated with negative recovery perceptions in an unadjusted model (OR: 1.05, 95% CI [1.01, 1.10], p < .01), but not after adjustment of covariates.

Conclusions: In contrast with cognitive and functional measures, depressive symptoms were strongly associated with cardiac arrest survivors' negative recovery perceptions at 6-months post-discharge.
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http://dx.doi.org/10.1016/j.jcrc.2018.12.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379069PMC
April 2019

Early myoclonus following anoxic brain injury.

Neurol Clin Pract 2018 Jun;8(3):249-256

Departments of Neurology (ASR, BR, MGH, DR, WR, AV, CKC, AP, SA, SP, DJR, JC), Medicine (DB, LER), and Anesthesiology (VKM), Columbia University Medical Center; and Department of Neurology (MGH), New York University Medical Center, New York.

Background: It is unknown whether postanoxic cortical and subcortical myoclonus are distinct entities with different prognoses.

Methods: In this retrospective cohort study of 604 adult survivors of cardiac arrest over 8.5 years, we identified 111 (18%) patients with myoclonus. Basic demographics and clinical characteristics of myoclonus were collected. EEG reports, and, when available, raw video EEG, were reviewed, and all findings adjudicated by 3 authors blinded to outcomes. Myoclonus was classified as cortical if there was a preceding, time-locked electrographic correlate and otherwise as subcortical. Outcome at discharge was determined using Cerebral Performance Category.

Results: Patients with myoclonus had longer arrests with less favorable characteristics compared to patients without myoclonus. Cortical myoclonus occurred twice as often as subcortical myoclonus (59% vs 23%, respectively). Clinical characteristics during hospitalization did not distinguish the two. Rates of electrographic seizures were higher in patients with cortical myoclonus (43%, vs 8% with subcortical). Survival to discharge was worse for patients with myoclonus compared to those without (26% vs 39%, respectively), but did not differ between subcortical and cortical myoclonus (24% and 26%, respectively). Patients with cortical myoclonus were more likely to be discharged in a comatose state than those with subcortical myoclonus (82% vs 33%, respectively). Among survivors, good functional outcome at discharge was equally possible between those with cortical and subcortical myoclonus (12% and 16%, respectively).

Conclusions: Cortical and subcortical myoclonus are seen in every sixth patient with cardiac arrest and cannot be distinguished using clinical criteria. Either condition may have good functional outcomes.
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http://dx.doi.org/10.1212/CPJ.0000000000000466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6075972PMC
June 2018

Tracheostomy use, long-term survival, and neurological outcomes among cardiac arrest survivors.

Resuscitation 2018 08 19;129:e19-e20. Epub 2018 Jun 19.

Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States; Department of Neurology, Weill Cornell Medicine, New York, NY, United States.

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http://dx.doi.org/10.1016/j.resuscitation.2018.06.017DOI Listing
August 2018

Posttraumatic stress and depressive symptoms characterize cardiac arrest survivors' perceived recovery at hospital discharge.

Gen Hosp Psychiatry 2018 Jul - Aug;53:108-113. Epub 2018 May 10.

Department of Neurology, Columbia University Medical Center, New York, NY, United States. Electronic address:

Objective: To test the hypothesis that posttraumatic stress and depressive symptoms, not cognitive or functional impairment, are associated with cardiac arrest survivors' negative recovery perceptions at hospital discharge.

Methods: Prospective observational cohort of cardiac arrest patients admitted between 9/2015-5/2017. Survival to discharge with sufficient mental status to complete a psychosocial interview was the main inclusion criterion. Perceived recovery was assessed through the question, "Do you feel that you have made a complete recovery from your arrest?" The following measures were examined as potential correlates of perceived recovery: Repeatable Battery for Assessment of Neuropsychological Status, Modified Lawton Physical Self-Maintenance Scale, Barthel Index, Modified Rankin Scale, Cerebral Performance Category, Center for Epidemiological Studies-Depression (CES-D), and PTSD Checklist-Specific (PCL-S). Logistic regression evaluated associations between perceived recovery and potential correlates of recovery.

Results: 64/354 patients (58% men, 48% white, mean age 52 ± 17) were included. 67% (n = 43) had a negative recovery perception. There were no differences among patients' cognitive and functional domains. In individual models, patients with higher PCL-S and CES-D scores were more likely to have a negative recovery perception after adjusting for age and gender (OR: 1.2, 95% CI [1.1, 1.4], p = 0.003) and (OR: 1.1, 95% CI [1.0, 1.1], p = 0.05).

Conclusions: Within one month after a cardiac arrest event, survivors' negative recovery perceptions are associated with psychological distress.
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http://dx.doi.org/10.1016/j.genhosppsych.2018.02.006DOI Listing
November 2018

Predicting delayed cerebral ischemia after subarachnoid hemorrhage using physiological time series data.

J Clin Monit Comput 2019 Feb 20;33(1):95-105. Epub 2018 Mar 20.

Department of Biomedical Informatics, Columbia University, New York, NY, USA.

To develop and validate a prediction model for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) using a temporal unsupervised feature engineering approach, demonstrating improved precision over standard features. 488 consecutive SAH admissions from 2006 to 2014 to a tertiary care hospital were included. Models were trained on 80%, while 20% were set aside for validation testing. Baseline information and standard grading scales were evaluated: age, sex, Hunt Hess grade, modified Fisher Scale (mFS), and Glasgow Coma Scale (GCS). An unsupervised approach applying random kernels was used to extract features from physiological time series (systolic and diastolic blood pressure, heart rate, respiratory rate, and oxygen saturation). Classifiers (Partial Least Squares, linear and kernel Support Vector Machines) were trained on feature subsets of the derivation dataset. Models were applied to the validation dataset. The performances of the best classifiers on the validation dataset are reported by feature subset. Standard grading scale (mFS): AUC 0.58. Combined demographics and grading scales: AUC 0.60. Random kernel derived physiologic features: AUC 0.74. Combined baseline and physiologic features with redundant feature reduction: AUC 0.77. Current DCI prediction tools rely on admission imaging and are advantageously simple to employ. However, using an agnostic and computationally inexpensive learning approach for high-frequency physiologic time series data, we demonstrated that our models achieve higher classification accuracy.
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http://dx.doi.org/10.1007/s10877-018-0132-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6681895PMC
February 2019

Women have worse cognitive, functional, and psychiatric outcomes at hospital discharge after cardiac arrest.

Resuscitation 2018 04 3;125:12-15. Epub 2018 Feb 3.

Department of Neurology, Columbia University College of Physicians & Surgeons, New York Presbyterian Hospital/Columbia, New York, NY 10032, United States.

Aim: To examine gender differences among cardiac arrest (CA) survivors' cognitive, functional, and psychiatric outcomes at discharge.

Methods: This is a prospective, observational cohort of 187 CA patients admitted to Columbia University Medical Center, considered for Targeted Temperature Management (TTM), and survived to hospital discharge between September 2015 and July 2017. Patients with sufficient mental status at hospital discharge to engage in the Repeatable Battery for Neuropsychological Status (RBANS), Modified Lawton Physical Self-Maintenance Scale (M-PSMS), Cerebral Performance Category Scale (CPC), Center for Epidemiological Studies Depression Scale (CES-D), and Post-Traumatic Stress Disorder Checklist - Civilian Version (PCL-C) were included. Fisher's exact, Wilcoxon Rank Sum, and regression analysis were utilized.

Results: 80 patients (38% women, 44% white, mean age 53 ± 17 years) were included. No significant gender differences were found for age, race, Charlson Comorbidity Index, premorbid CPC or psychiatric diagnoses, arrest related variables, discharge CPC, or PCL-C scores. Women had significantly worse RBANS (64.9 vs 74.8, p = .01), M-PSMS (13.6 vs 10.6, p = .02), and CES-D (22.8 vs 14.3, p = .02) scores. These significant differences were maintained in multivariate models after adjusting for age, initial rhythm, time to return of spontaneous circulation, and TTM.

Conclusions: Women have worse cognitive, functional, and psychiatric outcomes at hospital discharge after cardiac arrest than men. Identifying factors contributing to these differences is of great importance in cardiac arrest outcomes research.
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http://dx.doi.org/10.1016/j.resuscitation.2018.01.036DOI Listing
April 2018

Duration of Agitation, Fluctuations of Consciousness, and Associations with Outcome in Patients with Subarachnoid Hemorrhage.

Neurocrit Care 2018 08;29(1):33-39

Department of Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8GS-300, New York, NY, 10032, USA.

Background: Agitation is common after subarachnoid hemorrhage (SAH) and may be independently associated with outcomes. We sought to determine whether the duration of agitation and fluctuating consciousness were also associated with outcomes in patients with SAH.

Methods: We identified all patients with positive Richmond Agitation Sedation Scale (RASS) scores from a prospective observational cohort of patients with SAH from 2011 to 2015. Total duration of agitation was extrapolated for each patient using available RASS scores, and 24-h mean and standard deviation (SD) of RASS scores were calculated for each patient. We also calculated each patient's duration of substantial fluctuation of consciousness, defined as the number of days with 24-h RASS SD > 1. Patients were stratified by 3-month outcome using the modified Rankin scale, and associations with outcome were assessed via logistic regression.

Results: There were 98 patients with at least one positive RASS score, with median total duration of agitation 8 h (interquartile range [IQR] 4-18), and median duration of substantially fluctuating consciousness 2 days (IQR 1-3). Unfavorable 3-month outcome was significantly associated with a longer duration of fluctuating consciousness (odds ratio [OR] per day, 1.51; 95% confidence interval [CI], 1.04-2.20; p = 0.031), but a briefer duration of agitation (OR per hour, 0.94; 95% CI, 0.89-0.99; p = 0.031).

Conclusion: Though a longer duration of fluctuating consciousness was associated with worse outcomes in our cohort, total duration of agitation was not, and may have had the opposite effect. Our findings should therefore challenge the intensity with which agitation is often treated in SAH patients.
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http://dx.doi.org/10.1007/s12028-017-0491-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6447285PMC
August 2018

Determinants of Long-Term Neurological Recovery Patterns Relative to Hospital Discharge Among Cardiac Arrest Survivors.

Crit Care Med 2018 02;46(2):e141-e150

All authors: Department of Neurology, Columbia University Medical Center, New York, NY.

Objective: To explore factors associated with neurological recovery at 1 year relative to hospital discharge after cardiac arrest.

Design: Observational, retrospective review of a prospectively collected cohort.

Setting: Medical or surgical ICUs in a single tertiary care center.

Patients: Older than 18 years, resuscitated following either in-hospital or out-of-hospital cardiac arrest and considered for targeted temperature management between 2007 and 2013.

Interventions: None.

Measurements And Main Results: Logistic regressions to determine factors associated with a poor recovery pattern after 1 year, defined as persistent Cerebral Performance Category Score 3-4 or any worsening of Cerebral Performance Category Score relative to discharge status. In total, 30% (117/385) of patients survived to hospital discharge; among those discharged with Cerebral Performance Category Score 1, 2, 3, and 4, good recovery pattern was seen in 54.5%, 48.4%, 39.5%, and 0%, respectively. Significant variables showing trends in associations with a poor recovery pattern (62.5%) in a multivariate model were age more than 70 years (odds ratio, 4; 95% CIs, 1.1-15; p = 0.04), Hispanic ethnicity (odds ratio, 4; CI, 1.2-13; p = 0.02), and discharge disposition (home needing out-patient services (odds ratio, 1), home requiring no additional services (odds ratio, 0.15; CI, 0.03-0.8; p = 0.02), acute rehabilitation (odds ratio, 0.23; CI, 0.06-0.9; p = 0.04).

Conclusions: Patients discharged with mild or moderate cerebral dysfunction sustained their risk of neurological worsening within 1 year of cardiac arrest. Old age, Hispanic ethnicity, and discharge disposition of home with out-patient services may be associated with a poor 1 year neurological recovery pattern after hospital discharge from cardiac arrest.
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http://dx.doi.org/10.1097/CCM.0000000000002846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5771814PMC
February 2018

Transcranial Doppler Waveforms During Intra-aortic Balloon Pump Counterpulsation for Vasospasm Detection After Subarachnoid Hemorrhage.

Neurosurgery 2018 09;83(3):416-421

Department of Neurology, Columbia University Medical Center, New York, New York.

Background: Transcranial Doppler ultrasound is a standard screening tool for vasospasm after subarachnoid hemorrhage. Prevention of vasospasm-induced delayed cerebral ischemia after subarachnoid hemorrhage depends on optimization of cerebral perfusion pressure, which can be challenged by neurogenic stress cardiomyopathy. Intra-aortic balloon pumps have been utilized to augment cerebral perfusion, but they change the transcranial Doppler waveform, altering its interpretability for vasospasm screening.

Objective: To assess the features of the transcranial Doppler waveform that correlate with vasospasm.

Methods: We retrospectively reviewed cases of subarachnoid hemorrhage that underwent same-day transcranial Doppler ultrasound and angiography. Transcranial Doppler waveforms were assessed for mean velocity, peak systolic velocity, balloon pump-augmented diastolic velocity, and a novel feature, "delta velocity" (balloon pump-augmented velocity - systolic velocity). Relationship of flow velocity features to vasospasm was estimated by generalized estimating equation models using a Gaussian distribution and an exchangeable correlation structure.

Results: There were 31 transcranial Doppler and angiography pairings (12 CT angiography/19 digital subtraction angiography) from 4 patients. Fourteen pairings had proximal vasospasm by angiography. Delta velocity was associated with proximal vasospasm (coefficient -6.8 [95% CI -9.8 to -3.8], P < .001). There was no significant correlation with proximal vasospasm for mean velocity (coefficient -13.0 [95% CI -29.3 to 3.4], P = .12), systolic velocity (coefficient -8.7 [95% CI -24.8 to 7.3], P = .29), or balloon pump-augmented velocity (coefficient -15.3 [95% CI -31.3 to 0.71], P = .06).

Conclusion: Delta velocity, a novel transcranial Doppler flow velocity feature, may reflect vasospasm in patients with subarachnoid hemorrhage and intra-aortic balloon pumps.
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http://dx.doi.org/10.1093/neuros/nyx405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454792PMC
September 2018

Post-anoxic quantitative MRI changes may predict emergence from coma and functional outcomes at discharge.

Resuscitation 2017 08 15;117:87-90. Epub 2017 Jun 15.

Department of Neurology, Columbia University, New York, NY, USA. Electronic address:

Background: Traditional predictors of neurological prognosis after cardiac arrest are unreliable after targeted temperature management. Absence of pupillary reflexes remains a reliable predictor of poor outcome. Diffusion-weighted imaging has emerged as a potential predictor of recovery, and here we compare imaging characteristics to pupillary exam.

Methods: We identified 69 patients who had MRIs within seven days of arrest and used a semi-automated algorithm to perform quantitative volumetric analysis of apparent diffusion coefficient (ADC) sequences at various thresholds. Area under receiver operating characteristic curves (ROC-AUC) were estimated to compare predictive values of quantitative MRI with pupillary exam at days 3, 5 and 7 post-arrest, for persistence of coma and functional outcomes at discharge. Cerebral Performance Category scores of 3-4 were considered poor outcome.

Results: Excluding patients where life support was withdrawn, ≥2.8% diffusion restriction of the entire brain at an ADC of ≤650×10m/s was 100% specific and 68% sensitive for failure to wake up from coma before discharge. The ROC-AUC of ADC changes at ≤450×10mm/s and ≤650×10mm/s were significantly superior in predicting failure to wake up from coma compared to bilateral absence of pupillary reflexes. Among survivors, >0.01% of diffusion restriction of the entire brain at an ADC ≤450×10m/s was 100% specific and 46% sensitive for poor functional outcome at discharge. The ROC curve predicting poor functional outcome at ADC ≤450×10mm/s had an AUC of 0.737 (0.574-0.899, p=0.04).

Conclusion: Post-anoxic diffusion changes using quantitative brain MRI may aid in predicting persistent coma and poor functional outcomes at hospital discharge.
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http://dx.doi.org/10.1016/j.resuscitation.2017.06.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751429PMC
August 2017

Agitation After Subarachnoid Hemorrhage: A Frequent Omen of Hospital Complications Associated with Worse Outcomes.

Neurocrit Care 2017 Jun;26(3):428-435

Department of Critical Care Neurology, Columbia University Medical Center, 177 Fort Washington Avenue, Milstein Hospital Building, Suite 8-300, New York, NY, 10032, USA.

Background: Agitated delirium is frequent following acute brain injury, but data are limited in patients with subarachnoid hemorrhage (SAH). We examined incidence, risk factors, and consequences of agitation in these patients in a single-center retrospective study.

Methods: We identified all patients treated with antipsychotics or dexmedetomidine from a prospective observational cohort of patients with spontaneous SAH. Agitation was confirmed by chart review. Outcomes were assessed at 12 months using the modified Rankin Scale (mRS), Telephone Interview for Cognitive Status (TICS), and Lawton IADL (Instrumental Activities of Daily Living) scores. Independent predictors were identified using logistic regression.

Results: From 309 SAH patients admitted between January 2011 and December 2015, 52 (17 %) developed agitation, frequently in the first 72 h (50 %) and in patients with Hunt-Hess grades 3-4 (12 % of grades 1-2, 28 % of grades 3-4, 8 % of grade 5). There was also a significant association between agitation and a history of cocaine use or prior psychiatric diagnosis. Agitated patients were more likely to develop multiple hospital complications; and in half of these patients, complications were diagnosed within 24 h of agitation onset. Agitation was associated with IADL impairment at 12 months (Lawton >8; p = 0.03, OR 2.7, 95 % CI, 1.1-6.8) in non-comatose patients (Hunt-Hess 1-4), but not with functional outcome (mRS >3), cognitive impairment (TICS ≤30), or ICU/hospital length of stay after controlling for other predictors.

Conclusion: Agitation occurs frequently after SAH, especially in non-comatose patients with higher clinical grades. It is associated with the development of multiple hospital complications and may have an independent impact on long-term outcomes.
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http://dx.doi.org/10.1007/s12028-016-0331-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5548417PMC
June 2017

Intracranial Multimodality Monitoring for Delayed Cerebral Ischemia.

J Clin Neurophysiol 2016 Jun;33(3):241-9

Department of Neurology, Division of Critical Care and Hospitalist Neurology, Columbia University, New York, New York, U.S.A.

Management of patients with aneurysmal subarachnoid hemorrhage focuses on prevention of rebleeding by early treatment of the aneurysm, as well as detection and management of neurologic and medical complications. Early detection of delayed cerebral ischemia and management of modifiable contributing causes such as vasospasm take a central role, with the goal of preventing irreversible cerebral injury. In efforts to prevent delayed cerebral ischemia, multimodality monitoring has emerged as a promising tool in detecting subclinical physiologic changes before infarction occurs. However, there has been much variability in the utilization of this technology. Recent consensus guidelines discuss the role of multimodality monitoring in acute brain injury. In this review, we evaluate these guidelines and the utility of each modality of multimodality monitoring in aneurysmal subarachnoid hemorrhage.
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http://dx.doi.org/10.1097/WNP.0000000000000277DOI Listing
June 2016
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