| Part Ⅰ: Ultrasound measurement of ONSD combined with TCD to evaluate the prognosis of patients with acute severe supratentorial intracerebral hemorrhageBackground and objective: Acute spontaneous severe supratentorial intracerebral hemorrhage is a life-threatening disease worldwide,often leading to poor outcome and death.The early neurological deterioration and death are mainly caused by brain tissue displacement or increased intracranial pressure(ICP),so the early diagnosis and treatment of ICP is of great significance to improve the prognosis of patients.Ultrasound measurement of optic nerve sheath diameter(ONSD)and transcranial Doppler(TCD)have become research hotspots in recent years for non-invasive,bedside,and convenient assessment of increased ICP.The purpose of this study was to explore the prognostic value of ONSD and TCD in patients with severe acute supratentorial intracerebral hemorrhage.Methods: This study prospectively enrolled patients with acute severe supratentorial intracerebral hemorrhage admitted to the neurological intensive care unit from January 2020 to June 2021,we recorded the clinical data of the patients,and performed ONSD and TCD examinations on the patients at the bedside.The patients’ ONSD value,bilateral middle cerebral artery(MCA),systolic velocity(Vs),diastolic velocity(Vd),mean velocity(Vm)and pulsatility index(PI)were recorded.After 90 days,the patients’ survival was followed up by telephone,the Glasgow Outcome Score(GOS)was used to evaluate the prognosis of patients,and the patients were divided into survival group and death group.The correlation between each variable and prognosis was evaluated by univariate analysis,and the independent parameters affecting prognosis were evaluated by multivariate logistic regression analysis.By establishing the receiver operating characteristic(ROC)curve,the optimal cut-off value and the area under the ROC curve were obtained.Results: A total of 85 patients were enrolled in this study,including 53 males,with a mean age of 63.2±12.5 years,and 34(40%)patients died within 90 days.Univariate analysis showed that older age(P<0.001),lower Glasgow Coma Scale(GCS)score(p<0.001),larger hematoma volume(P<0.001),larger midline shift(MLS)(p=0.02)were significantly associated with mortality;among TCD parameters,decreased bilateral hemisphere Vd(affected side P=0.003,unaffected side P=0.001)and increased bilateral hemisphere PI(P<0.001)were significantly associated with mortality;the ONSD of the death group was significantly bigger than that of the survival group(5.81±0.41 vs.5.16±0.38 mm,P<0.001).Multivariate logistic regression analysis showed that after adjusting for confounding factors,ONSD(OR1.297,95%CI: 1.053-1.598,P=0.015),unaffected side pulsatility index(UPI OR1.603,95%CI: 1.063-2.419,P=0.025),baseline GCS score(OR 0.654,95%CI:0.444-0.962,P=0.031),and baseline hematoma volume(OR 1.037,95%CI:1.004-1.071,P=0.029)were independent predictors of death within 90 days.The optimal cut-off value of ONSD for predicting death within 90 days was 5.47 mm,with the sensitivity of 82.4%,the specificity of 88.2%,and the area under the curve(AUC)was 0.879(95%CI: 0.791-0.940).The ONSD was negatively correlated with the 90-day follow-up GOS score(r=-0.715,P<0.001).The combined AUC of ONSD,UPI,baseline GCS score,and baseline hematoma volume was 0.950(95%CI:0.880-0.986),and the diagnostic efficacy was better than ONSD(AUC 0.879(95%CI:0.791-0.940)),UPI(AUC 0.839(95%CI: 0.743-0.910)),GCS(AUC 0.817(95%CI:0.718-0.892))and hematoma volume(AUC 0.859(95%CI: 0.766-0.925))alone(all P<0.05).Conclusion: Ultrasound measurement of ONSD combined with TCD examination can be used as a new multimodal monitoring method in neurological intensive care unit.ONSD and TCD combined with patients’ baseline GCS score and baseline hematoma volume can improve the diagnostic efficiency of prognosis in patients with acute supratentorial severe intracerebral hemorrhage.Part II: Ultrasound measurement of ONSD combined with TCD to predict the occurrence of malignant middle cerebral artery infarctionBackground and objective: Large hemispheric infarction(LHI)is a severe type of ischemic stroke.The neurological deterioration and space-occupying brain edema caused by LHI in the early stage will lead to high mortality rate if not treated with timely surgical intervention,which called malignant middle cerebral artery infarction(MMI).The purpose of the study was to explore the predictive value of ultrasound measurement of ONSD combined with TCD on the occurrence of MMI in LHI patients,and to provide a new reference index for early identification of the occurrence of MMI in LHI patients and prognosis evaluation in patients with severe cerebral infarction.Methods: This study prospectively enrolled patients with acute LHI admitted to the intensive care unit of neurology department from January 2020 to June 2021,and divided the patients into MMI group and non-MMI group according to whether MMI occurred.The clinical data of the patients were recorded,ONSD and TCD examinations were performed on the patients at the bedside,the ONSD and TCD-related parameters of the patients were recorded.After 90 days,the patients’ survival was followed up by telephone.The correlation between each variable and MMI was evaluated by univariate analysis,and multivariate logistic regression analysis was established to evaluate the independent predictors of MMI.By establishing the receiver operating characteristic(ROC)curve,the optimal cut-off value and the area under the ROC curve were obtained.Results: A total of 81 patients were enrolled in this study,with a mean age of67.1±12.0 years and 56 males(69.1%).Among them,there were 35 cases(43.2%)in the MMI group and 46 cases(56.8%)in the non-MMI group.Thirty six patients(44.4%)died during the follow-up period.Univariate analysis showed that younger age(P=0.043),lower GCS score at admission(P<0.001),and higher National Institutes of Health Stroke Scale(NIHSS)score(P<0.001)were significantly associated with MMI;the ONSD in the MMI group was significantly bigger than that in the non-MMI group(5.52±0.34 vs.4.99±0.45 mm,P<0.001);TCD parameters didn’t correlate with whether patients occurred MMI.Multivariate logistic regression analysis showed that after adjusting for confounders,ONSD(OR 1.302,95%CI:1.114-1.521,P=0.001)and baseline NIHSS score(OR 1.170,95%CI: 1.055-1.297,P=0.003)were independent predictors of MMI in LHI patients.The optimal cut-off value of ONSD for predicting MMI was 5.27 mm,the sensitivity was 77.1%,the specificity was 78.3%,and the area under the curve(AUC)was 0.830(95%CI:0.731-0.905).The ONSD was negatively correlated with the 90-day follow-up GOS score(r=-0.497,P<0.001).Conclusion: Ultrasound measurement of ONSD can be used as a new indicator to identify the occurrence of MMI in LHI patients,and provide reference value for whether LHI patients need decompressive craniectomy in the early stage.Part III: Correlation between ultrasound measurement of ONSD combined with TCD and prognosis of patients with acute anterior circulation endovascular therapyBackground and objective: Acute ischemic stroke(AIS)patients with large vessel occlusion have a worse prognosis,and endovascular treatment(EVT)is widely regarded as the first-line treatment method for patients with acute large vessel occlusion.However,the incidence of poor prognosis is still around 50%.Elevated ICP and displacement of brain tissue in patients after EVT can lead to severe neurological impairment,which affects prognosis.Since previous studies have shown that ultrasound measurement of ONSD can non-invasively assess elevated ICP,and TCD can assess abnormal cerebral blood flow,the study aimed to explore the role of ultrasound measurement of ONSD combined with TCD examination in assessing the poor outcome of EVT patients.Methods: This study prospectively enrolled patients with acute anterior circulation large vessel occlusion who received EVT and were admitted to the neurological intensive care unit from January 2020 to June 2021.The clinical data of the patients were recorded,ONSD and TCD examinations were performed on the patients at the bedside within 24 hours after surgery,the ONSD and TCD-related parameters of the patients were recorded,and the thrombolysis in brain ischemia(TIBI)was assessed by TCD.After 90 days,the patients were followed up by telephone,and the patients were evaluated using the modified Rankin scale(m RS).Univariate analysis was performed to evaluate the correlation between each variable and poor outcome of patients,and multivariate logistic regression analysis was established to identify independent predictors of poor outcome.By establishing the receiver operating characteristic(ROC)curve,the optimal cut-off value and the area under the ROC curve were obtained.Results: A total of 70 patients were enrolled in this study,with a median age of65(56-69)years and 52 males(74.3%).During the 90-day follow-up,41 patients(58.6%)had poor outcome(m RS>2 points),29 patients(41.4%)had good outcome(m RS≤2 points),and 16 patients(22.9%)died during the follow-up period.Univariate analysis showed that patients with diabetes(P=0.035),higher NIHSS score at admission(P=0.002),and tandem lesions(P=0.021)had poor clinical outcomes;among TCD parameters,patients with affected side diastolic velocity(Vd)(P=0.040),TIBI grade(P<0.001)were significantly correlated with poor outcome;the ONSD in the poor outcome group was significantly bigger than that in the good outcome group(5.30±0.40 vs.4.73±0.36 mm,P<0.001).Multivariate logistic regression analysis showed that after adjusting for confounding factors,ONSD(OR 1.515,95%CI:1.211-1.896,P<0.001)and TIBI grade(OR 0.311,95%CI: 0.135-0.719,P= 0.006)were independent predictors of poor outcome in EVT patients.The optimal cut-off value of ONSD for predicting poor outcome in EVT patients was 5.18 mm,with the sensitivity of 61.0%,the specificity of 96.6%,and the area under the curve(AUC)of0.842(95% CI: 0.736-0.918).The ONSD was positively correlated with NIHSS score at discharge(r=0.445,P<0.001)and m RS score at 90 days follow-up(r=0.582,P<0.001).Conclusion: Ultrasound measurement of ONSD and TCD to assess TIBI classification after EVT can predict the poor outcome of patients.Ultrasound measurement of ONSD combined with TCD monitoring can provide valuable guidance for postoperative blood flow changes and ICP monitoring in patients with EVT. |
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