Mucormycosis is a rare but life-threatening invasive fungal infection that primarily affects immunocompromised patients. Data on its presentation, management, and prognosis in the intensive care unit setting remain scarce. We aimed to evaluate 90-day mortality and to explore clinical, microbiological, therapeutic, and immunological factors associated with outcome in critically ill patients with mucormycosis. This retrospective multicenter cohort study included patients diagnosed with mucormycosis and admitted to the ICUs of the Hospices Civils de Lyon between January 2014 and July 2023. Patients were identified through mycological records and hospital discharge codes. Univariable analysis and multivariable Cox model were performed to identify factors associated with 90-day mortality. Among 43 patients included, hematological malignancy and trauma were the most common underlying conditions (26

Importance Functional outcomes and long-term recovery after severe encephalitis are not well characterized. Objective To determine the incidence of functional disability or death at 3 months and to describe recovery trajectories through 1 year after encephalitis. Design, Setting, and Participants This prospective multicenter cohort study was conducted across 31 French centers from October 2017 to April 2021 and included adults with probable or confirmed encephalitis and clear cerebrospinal fluid findings requiring care in the intensive care unit. Data analysis was performed between May 2023 and June 2025. Exposure Causes of encephalitis were categorized into 4 different groups: infectious, autoimmune, other causes, and unknown origin. Main Outcomes and Measures The primary end point was an unfavorable outcome at 3 months, defined by a modified Rankin scale score of 3 to 6, indicating moderate to severe disability or death. Results Among the 310 patients included (median [IQR] age, 60 [43-70] years; 177 male [57.1%]), 123 (39.7%) were diagnosed with infectious encephalitis, 42 (13.5%) with autoimmune encephalitis, 37 (11.9%) with other encephalitis causes, and 108 (34.8%) with encephalitis of unknown origin. Overall, 161 patients (51.9%; 95% CI, 46.2%-57.6%) had an unfavorable outcome at 3 months, including 84 deaths (27.1%). Independent factors associated with unfavorable outcome included age (odds ratio [OR] per 5-year increment, 1.28, 95% CI, 1.16 to 1.41) and immunocompromised status (OR, 3.12; 95% CI, 1.57 to 6.40), while intravenous acyclovir on the day of ICU admission was associated with a favorable outcome (OR, 0.38; 95% CI, 0.20 to 0.72). The proportion of patients achieving functional independence remained stable from 3 months to 1 year (difference in proportions, 1.1%; 95% CI, -6.9% to 9.2%). Analyses based on encephalitis cause groups revealed that patients with autoimmune encephalitis showed significant improvement through 1 year (difference in proportions, 8.9%; 95% CI, 1.2% to 16.6%), whereas no significant changes were seen in patients with infectious causes (difference in proportions, 1.2%; 95% CI, -6.9% to 9.2%), other causes (difference in proportions, 1.2%; 95% CI: -6.8% to 9.2%), or unknown origin (difference in proportions, -1.9%; 95% CI: -10.0% to 6.2%). Conclusions and Relevance In this cohort study of adults with severe encephalitis requiring intensive care, one-half of patients had an unfavorable outcome at 3 months. Functional recovery at 1 year varied by cause of encephalitis, with patients with autoimmune encephalitis experiencing more favorable outcomes than those with other causes, suggesting a possible role for targeted long-term support in certain cases.

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with significant morbidity, particularly related to delayed cerebral ischemia (DCI). Hyponatremia, defined as a serum sodium level < 135 mmol/l, is a common complication of aSAH and is associated with the development of DCI. Fludrocortisone is used to decrease natriuresis and improve hyponatremia, but has failed to demonstrate a reduction in the frequency of cerebral vasospasm or DCI. Using the ProReSHA database, we retrospectively analyzed the impact of fludrocortisone on the development of DCI in patients hospitalized in neurocritical care unit after aSAH and presenting hyponatremia. Two hundred sixteen patients were included, 88 in the fludrocortisone group and 128 in the control group. DCI occurred in 35 (39.8%) patients in the fludrocortisone group and 34 (26.6%) in the control group (p = 0.058). Hyponatremia was significantly deeper in the fludrocortisone group than in the control group (median [interquartile range]: 130 [128-131] vs. 132 [131-133] mmol/l; p < 0.001), and lasted longer (6.0 [4.0-8.3] vs. 3.0 [2.0-5.0] days; p < 0.001). An ancillary analysis stratified according to the etiology of hyponatremia (cerebral salt wasting syndrome or syndrome of inappropriate secretion of antidiuretic hormone) also found no significant difference regarding DCI occurrence (33.3% vs. 44.6%; p = 0.238) but a significantly lower natriuresis in the cerebral salt wasting syndrome group (225 [187-308] vs. 293 [253-359] mmol/d; p = 0.01). Fludrocortisone did not prevent the development of DCI in patients admitted to a neurocritical care unit for an aneurysmal subarachnoid hemorrhage and presenting with hyponatremia. Effect of fludrocortisone in the management of hyponatremia after aneurysmal subarachnoid hemorrhage.

Intracranial pressure (ICP) monitoring is commonly used in neuro-intensive care, but its utility may be limited by a suboptimal use. The brain pressure-volume relationship, a potential predictor of neurological health, is now approached using time-domain methods, which can be challenging to implement. Frequency-domain methods may offer an alternative, but their relationship with time-domain metrics remains unclear. This study compares time- and frequency-domain methods for assessing brain compliance and evaluates their real-time usability. A monocentric, prospective observational study was conducted in the neurological ICU of the Hospices Civils de Lyon, France, to evaluate markers of brain compliance. Adult patients with brain lesions requiring multimodal monitoring were included. Continuous high-density physiological data, including ICP, arterial blood pressure (ABP), end-tidal CO₂, and electrocardiogram (ECG), were collected for analysis. Some spontaneous ICP rise events were automatically detected based on heuristic criteria and used as brain compliance challenges to compare the co-evolution of metrics across multiple time windows. Time-domain (pulse shape-related metrics) and frequency-domain analyses (examining heart and respiratory components in ICP) were computed to assess the intracranial pressure-volume state. Statistical analyses were performed using linear mixed-effects modeling, adjusting for vasoactive and sedative medications and Spearman correlations. The study included 66 patients, with a mean age of 49.16 [38.38, 57.58] years. A total of 518 spontaneous ICP rise events were detected in 56 patients. Our findings revealed that: 1) frequency-domain metrics strongly correlated with time-domain metrics during these challenges (r > 0.8, p < 0.001), 2) frequency-domain metrics were significantly drastically less computationally demanding, and 3) the impact of the heart on ICP showed a significant correlation with the P2/P1 ratio (r = 0.391, p < 0.001) and other potential markers of brain compliance. In contrast, the impact of respiration on ICP was only marginally correlated with these markers. Frequency-domain analyses exploring the impact of cardiac activity on ICP map provide similarly informative value to more complex machine learning-based tools, but with the advantage of being much less computationally demanding. This makes this approach particularly suitable and intuitive for real-time clinical monitoring in hospital settings, where computational resources are often limited. Initials: VG, NE, GP, LB, FG, RC, CB, FC, AM, AR, RM, FD, TR, SG, BB Conception and Design: VG, NE, BB Data Collection : VG, NE, LB, GP, TR, FG, RC, CB, FC, FD, BB Data Analysis and Interpretation: VG, BB Methodology Development: VG, BB, SG Manuscript Drafting and Writing: VG, BB Supervision and Project Oversight: BB Funding Acquisition: BB, VG Visualization: VG, BB Critical Review and Editing: NE, GP, LB, FG, RC, CB, FC, AM, AR, RM, FD, TR, SG, BB Approval of the Final Version: All Software Development: VG, SG Ethical Approval and Regulatory Compliance: BB

Citrate accumulation (CA) is a feared complication in critically ill patients undergoing regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT). This study aimed to describe the characteristics of patients presenting CA within a large cohort of unselected critically ill patients receiving RCA-CRRT depending on the time of occurrence of CA after CRRT initiation. This retrospective, multicenter observational study performed in nine intensive care units (ICU) in Lyon, France, included patients treated with RCA-CRRT between January 2020 and January 2022. CA was defined by a total to ionized calcium ratio (tCa/iCa) ≥ 2.3 associated with hypocalcemia and metabolic acidosis. Among 2080 patients, 76 (3.7

The end-stage of amyotrophic lateral sclerosis (ALS) is commonly regarded as a complete Locked-In Syndrome (cLIS). Shifting the perspective from cLIS (assumed consciousness) to Cognitive Motor Dissociation (potentially demonstrable consciousness), we aimed to assess the preservation of covert awareness (internally preserved but externally inaccessible) using a multimodal battery. We evaluate two end-stage ALS patients using neurophysiological testing, passive and active auditory oddball paradigms, an auditory Brain-Computer Interface (BCI), functional activation-task imaging, long-term EEG, brain morphology, and resting-state metabolism to characterize underlying brain function. Patient 1 initially follows simple commands but fails twice at BCI control. At follow-up, command following is no longer observed and his oddball cognitive responses disappear. Patient 2, at a single evaluation, is unable to follow commands or control the BCI. Both patients exhibit altered wakefulness, brain atrophy, and a global cortico–subcortical hypometabolism pattern consistent with a disorder of consciousness, regarded as an extreme manifestation of ALS-associated fronto-temporal dementia. Although it is not possible to firmly prove the absence of awareness, each independent measure concurred with suggesting that a “degenerative disorder of consciousness” rather than a cLIS may constitute the final stage of ALS. This condition appears pathophysiologically distinct from typical tetraplegia and anarthria, in which behavioural communication and BCI use persist to enhance quality of life. Identifying the neuroimaging signatures of this condition represents a substantial milestone in understanding end-stage ALS. Large-scale longitudinal investigations are warranted to determine the prevalence of this profile among patients whose communication appears impossible. Some patients with amyotrophic lateral sclerosis become progressively paralyzed to the extent that they can no longer communicate. This raises a critical question: does consciousness remain despite a complete loss of interaction? To address this issue, we analysed brain activity in two patients at the late stage of this disease. Our findings indicate that no reliable signs of awareness could be detected, even when employing advanced methods to assess brain function, including approaches designed to enable communication without movement. Two hypotheses may account for this outcome: either prolonged paralysis progressively leads to the disappearance of consciousness, or the degeneration of brain function itself directly underlies its loss. However, our conclusions ultimately depend on the reliability of consciousness assessment tools, even when used in combination. Gobert et al. investigate whether consciousness persists in end-stage Amyotrophic Lateral Sclerosis, traditionally assumed as being fully aware but unable to communicate. Multimodal assessments, including Brain-Computer Interface, suggest some individuals may show degenerative disorder of consciousness rather than a complete Locked-In Syndrome.

The continuous monitoring of physiological parameters is now considered as a standard of care in intensive care units (ICU). While multiple techniques are available to guide hemodynamic or respiratory management, the monitoring of neurological function in unconscious patients is usually limited to discontinuous bedside neurological examination or morphological brain imaging. However, cortical activity is accessible at the bedside with electroencephalography (EEG), electrocorticography (ECoG) or evoked potentials. The analysis of the unprocessed signal requires a trained neurophysiologist and could be time consuming. During the past decades, advances in neurophysiological signal acquisition make it possible to calculate quantified EEG parameters in real-time. New monitors also provide ICU friendly display for a dynamic and live assessment of neurological function changes. In this review, we will describe the technical aspects of EEG, ECoG and evoked potentials required for a good signal quality before interpretation. We will discuss how to use those electrophysiological techniques in the ICU to assess neurological function in comatose patients at the acute phase of brain injuries such as traumatic brain injuries, haemorrhagic or ischemic stroke. We will discuss, which quantitative EEG or evoked potentials monitoring parameters can be used at the bedside to guide sedation, evaluate neurological function during awaking and look for new neurological (encephalic or brainstem) injuries. We will present the state of the art and discuss some analyses, which may develop shortly.

The recent SarsCov2 pandemic has disrupted healthcare system notably impacting intensive care units (ICU). In severe cases, the immune system is dysregulated, associating signs of hyperinflammation and immunosuppression. In the present work, we investigated, using a joint modeling approach, whether the trajectories of cellular immunological parameters were associated with survival of COVID-19 ICU patients. This study is based on the REA-IMMUNO-COVID cohort including 538 COVID-19 patients admitted to ICU between March 2020 and May 2022. Measurements of monocyte HLA-DR expression (mHLA-DR), counts of neutrophils, of total lymphocytes, and of CD4+ and CD8+ subsets were performed five times during the first month after ICU admission. Univariate joint models combining survival at day 28 (D28), hospital discharge and longitudinal analysis of those biomarkers' kinetics with mixed-effects models were performed prior to the building of a multivariate joint model. We showed that a higher mHLA-DR value was associated with a lower risk of death. Predicted mHLA-DR nadir cutoff value that maximized the Youden index was 5414 Ab/C and led to an AUC = 0.70 confidence interval (95%CI) = [0.65; 0.75] regarding association with D28 mortality while dynamic predictions using mHLA-DR kinetics until D7, D12 and D20 showed AUCs of 0.82 [0.77; 0.87], 0.81 [0.75; 0.87] and 0.84 [0.75; 0.93]. Therefore, the final joint model provided adequate discrimination performances at D28 after collection of biomarker samples until D7, which improved as more samples were collected. After severe COVID-19, decreased mHLA-DR expression is associated with a greater risk of death at D28 independently of usual clinical confounders.

The continuous monitoring of physiological parameters is now considered as a standard of care in intensive care units (ICU). While multiple techniques are available to guide hemodynamic or respiratory management, the monitoring of neurological function in unconscious patients is usually limited to discontinuous bedside neurological examination or morphological brain imaging. However, cortical activity is accessible at the bedside with electroencephalography (EEG), electrocorticography (ECoG) or evoked potentials. The analysis of the unprocessed signal requires a trained neurophysiologist and could be time consuming. During the past decades, advances in neurophysiological signal acquisition make it possible to calculate quantified EEG parameters in real-time. New monitors also provide ICU friendly display for a dynamic and live assessment of neurological function changes. In this review, we will describe the technical aspects of EEG, ECoG and evoked potentials required for a good signal quality before interpretation. We will discuss how to use those electrophysiological techniques in the ICU to assess neurological function in comatose patients at the acute phase of brain injuries such as traumatic brain injuries, haemorrhagic or ischemic stroke. We will discuss, which quantitative EEG or evoked potentials monitoring parameters can be used at the bedside to guide sedation, evaluate neurological function during awaking and look for new neurological (encephalic or brainstem) injuries. We will present the state of the art and discuss some analyses, which may develop shortly.

The end-stage of amyotrophic lateral sclerosis [ALS] is presumed to be a complete Locked-In Syndrome [cLIS], assuming an internally preserved consciousness that would not be accessible anymore from the outside. However, whether consciousness persists at this stage of ALS remains to be demonstrated. Shifting the perspective from cLIS (presupposed consciousness) to Cognitive Motor Dissociation (to-be-demonstrated consciousness), we attempted to demonstrate consciousness and communication with two cLIS-ALS patients using a multimodal awareness assessment battery. It involved complete neurophysiological assessments, passive and active auditory oddball paradigm (Subject-Own-Name/P300), an auditory-based Brain-Computer-Interface [BCI] and activation-task imaging using functional MRI or [15O]H2O PET. Wakefulness (long-term EEG), brain morphology (CT or MRI scans) and resting brain metabolism ([18F]fluoro-deoxy-glucose PET) were used to describe the underlying cLIS brain function. While Patient 1 could initially follow simple commands, he failed twice to control the BCI. At follow-up, he showed no more evidence of command following and his oddball (Own Name - P300) cognitive responses has disappeared. At his unique evaluation, Patient 2 was neither able to follow simple commands nor to control the BCI. Both patients had altered wakefulness, brain atrophy, and a global cortico-sub-cortical hypometabolism pattern compatible with a disorder of consciousness, regarded as an extreme form of an ALS-associated fronto-temporal dementia. While it is not possible to firmly demonstrate the absence of awareness, each independent measure concurred with suggesting that a degenerative disorder of consciousness rather than a cLIS might be the final stage of ALS. In future cass, this dramatic cognitive decline should be anticipated before communication disappears to enable precise advance directives regarding end-of-life issues in case complete, and neurophysiologically confirmed, unresponsiveness occurs. Altogether, the neuroimaging features distinguishing the mechanisms in this rare condition is a significant milestone to understand end-stage ALS. The present clinical study calls for further exploration of this terminal stage to determine the prevalence of this profile in whom communication seems hopeless. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement AO was funded by the Fondation pour la Recherche Medicale (FRM, ING20121226307). PS, JM, EM were funded by one grant from the Fondation pour la Recherche Medicale (FRM, FDM201906008524). JM, EM and PS were funded by ANR-17-CE40-0005, MindMadeClear & ANR-20-CE17-0023, ANR HiFi. PS was funded by Perce-Neige Fondation. The teams of the Lyon Neurocience Research Center are funded by the Labex cortex. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: IRB of Hospices Civils de LYON CSE-HCL - IRB 00013204; Pr Cyrille Confavreux gave ethical approval for this work (approval N. 24-310). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript.

This retrospective study aimed to compare the mortality and burden of respiratory syncytial virus (RSV group), SARS-CoV-2 (COVID-19 group), non-H1N1 (Seasonal influenza group) and H1N1 influenza (H1N1 group) in adult patients admitted to intensive care unit (ICU) with respiratory failure. A total of 807 patients were included. Mortality was compared between the four following groups: RSV, COVID-19, seasonal influenza, and H1N1 groups. Patients in the RSV group had significantly more comorbidities than the other patients. At admission, patients in the COVID-19 group were significantly less severe than the others according to the simplified acute physiology score-2 (SAPS-II) and sepsis-related organ failure assessment (SOFA) scores. Using competing risk regression, COVID-19 (sHR = 1.61; 95% CI 1.10; 2.36) and H1N1 (sHR = 1.87; 95% CI 1.20; 2.93) were associated with a statistically significant higher mortality while seasonal influenza was not (sHR = 0.93; 95% CI 0.65; 1.31), when compared to RSV. Despite occurring in more severe patients, RSV and seasonal influenza group appear to be associated with a more favorable outcome than COVID-19 and H1N1 groups.

Abstract Brain death, characterized by the permanent cessation of all brain functions including the brainstem, is subject to varying diagnostic criteria internationally. In France, the confirmation of the clinical criteria requires ancillary tests such as CT angiogram or EEG. The timing of these tests presents challenges, especially in the intensive care setting. This study outlines a novel approach for the assessment of brainstem and cortical functions, improving the precision of brain death diagnosis in high-workload intensive care environments. We detail the implementation of a continuous multimodal neuromonitoring system, utilizing electrocorticography to monitor cortical spreading depolarizations (SD) and employing advanced analytics to track variability in heart and respiratory rates as indicators of brainstem functions. The SD-ICU single-center trial assessed the feasibility and safety of SD monitoring in patients with acute brain injuries, using cortical electrodes. In conjunction with the Moberg CNS monitor, this setup allowed for the collection and analysis of multimodal neuromonitoring data. We highlight the case of a patient who, exhibited an SD-initiated negative ultraslow potential, indicating cortical death. Subsequent fluctuations in heart and respiratory rates’ variability provided a real-time evaluation of the functionality of the brainstem's cardiovascular and respiratory centers. The integration of SD monitoring and variability analyses offers a continuous bedside evaluation, presenting clinicians with real-time biomarkers of brainstem and cortical death. This method could be incorporated into neuromonitoring software, enabling more timely and precise brain death determinations, a paramount improvement given the complexities and demands of ICU care.

Le Doppler transcrânien, au même titre que l’examen ultrasonographique des autres organes, s’est imposé dans la prise en charge des patients critiques. Il se révèle utile pour le diagnostic du vasospasme dans les suites des hémorragies sous-arachnoïdiennes, dans la recherche d’une hypertension intracrânienne ou la recherche de facteur de mauvais pronostic dans les suites d’un traumatisme crânien, ou encore dans la recherche d’un arrêt circulatoire cérébral. Cet examen ne peut toutefois se concevoir qu’en complet de l’examen clinique et du bilan morphologique radiographique, et s’il est facile d’obtenir des valeurs, leur interprétation nécessite un minimum de connaissances physiopathologiques et d’expérience.

Abstract Background A 10-day dexamethasone regimen has emerged as the internationally adopted standard-of-care for severe COVID-19 patients. However, the immune response triggered by SARS-CoV-2 infection remains a complex and dynamic phenomenon, leading to various immune profiles and trajectories. The immune status of severe COVID-19 patients following complete dexamethasone treatment has yet to be thoroughly documented. Results To analyze monocyte HLA-DR expression (mHLA-DR) and CD4 + T lymphocyte count (CD4) in critically ill COVID-19 patients after a dexamethasone course and evaluate their association with 28-day ICU mortality, adult COVID-19 patients (n = 176) with an ICU length of stay of at least 10 days and under dexamethasone treatment were included. Associations between each biomarker value (or in combination) measured at day 10 after ICU admission and 28-day mortality in ICU were evaluated. At day 10, the majority of patients presented decreased values of both parameters. A significant association between low mHLA-DR and 28-day mortality was observed. This association remained significant in a multivariate analysis including age, comorbidities or pre-existing immunosuppression (adjusted Hazard ratio (aHR) = 2.86 [1.30–6.32], p = 0.009). Similar results were obtained with decreased CD4 + T cell count (aHR = 2.10 [1.09–4.04], p = 0.027). When combining these biomarkers, patients with both decreased mHLA-DR and low CD4 presented with an independent and significant elevated risk of 28-day mortality (i.e., 60%, aHR = 4.83 (1.72–13.57), p = 0.001). Conclusions By using standardized immunomonitoring tools available in clinical practice, it is possible to identify a subgroup of patients at high risk of mortality at the end of a 10-day dexamethasone treatment. This emphasizes the significance of integrating immune monitoring into the surveillance of intensive care patients in order to guide further immumodulation approaches.

The morbidity of aneurysmal subarachnoid hemorrhage (aSAH) remains high, particularly because of secondary cerebral lesions that significantly aggravate the primary lesions. The main type of secondary lesions is delayed cerebral ischemia (DCI), in which platelets (PLT) appear to play a key role. Mean platelet volume (MPV) is an indirect marker of platelet activation. We aimed to determine the individual trajectories of MPV over time in patients with and without DCI during the course of aSAH. This is a single-center, retrospective, longitudinal analysis of individual trajectories of MPV over time, in a cohort of aSAH patients included in the Prospective, Observational Registry of Patient with Subarachnoid Hemorrhage in Neurocritical Care Unit (ProReSHA). A mixed-effects linear regression model was used to compare the trajectories of MPV and MPV/PLT ratio between patients who developed a DCI and those who did not. A total of 3634 MPV values were collected in 587 patients. The analysis of MPV as a function of DCI occurrence showed a significant difference in the trajectory over time between patients with DCI and those without, with an estimate of 0.02 (95%CI 0.01, 0.04, p = 0.009). The analysis of the MPV/PLT ratio as a function of DCI occurrence and other covariates showed a significant difference in the trajectory over time only for patients with a modified Fisher score less than 3, with an estimate of -0.59 (95%CI: -0.94, -0.23, p = 0.001). The individual trajectories of MPV over time differ between patients with DCI and those without. However, MPV values vary greatly over time and between patients. Thus it does not appear as a reliable biomarker for stratifying patients based on their specific risk of developing DCI. ClinicalTrials.gov identifier: (NCT02890004), registered in August 2016.

En réanimation neurologique, l’évaluation clinique reste le meilleur moyen de surveiller l’état neurologique des patients et passe généralement par l’utilisation d’échelles et de scores standardisés. Ces outils sont nombreux et variés. Leur utilisation n’est cependant pas toujours pertinente et peut se révéler délétère pour le patient (surstimulation, inconfort, douleur). Notre démarche actuelle concerne l’adaptation de l’évaluation neurologique et vise à garder la meilleure sensibilité tout en limitant les sources d’inconfort pour le patient. Dans un premier, afin d’évaluer les pratiques des autres unités, une enquête a été réalisée au sein de plusieurs services de réanimation neurologique. Le questionnaire comprenait 2 parties : la première sur les habitudes du service en général (échelles utilisées, fréquence de cotation), la deuxième sur des situations cliniques identifiées (patient conscient, patient sédaté, patient confus, …). Il ressort que le score de Glasgow reste l’échelle de cotation neurologique la plus utilisée, malgré ses limites et ses contraintes vis-à-vis du patient. Par ailleurs, il ne semble pas y avoir d’adaptation du choix de la cotation en termes d’outil et de fréquence à la pathologie et à l’état clinique du patient.

BACKGROUND:Headache is the most common presenting symptom of spontaneous subarachnoid hemorrhage and managing this acute pain can be challenging. The aim of this study was to describe the course of headaches and factors associated with analgesic failure in patients with spontaneous subarachnoid hemorrhage.METHODS:We conducted a prospective observational study in patients admitted to a neurocritical care unit (between April 2016 and March 2017) within 48 hours of spontaneous subarachnoid hemorrhage. Headache intensity was assessed using a Numerical Pain Rating Scale (NPRS) ranging from 0 to 10. Analgesic failure was defined as any day average NPRS score >3 after 72 hours of hospitalization despite analgesic treatment.RESULTS:Sixty-three patients were included in the analysis. Thirty-six (56.25%) patients experienced at least 1 episode of severe headache (NPRS ≥7), and 40 (63.5%) patients still reported moderate to severe headache on the final day of the study (day 12). Forty-six (73.0%) patients required treatment with opioids and 37 (58.7%) experienced analgesic failure. Multivariable analysis showed that analgesic failure was associated with smoking history (odds ratio [OR]=4.31, 95% confidence interval [CI]: 1.23-17.07; P =0.027), subarachnoid blood load (OR=1.11, 95% CI: 1.01-1.24; P =0.032) and secondary complications, including rebleeding, hydrocephalus, delayed cerebral ischemia, hyponatremia, or death (OR=4.06, 95% CI: 1.17-15.77; P =0.032).CONCLUSIONS:Headaches following spontaneous subarachnoid hemorrhage are severe and persist during hospitalization despite standard pain-reducing strategies. We identified risk factors for analgesic failure in this population.

Objective: Early functional evaluation and prognosis of patients with disorders of consciousness is a major challenge that clinical assessments alone cannot solve. Objective measures of brain activity could help resolve this uncertainty. We used electroencephalogram at bedside to detect voluntary attention with a paradigm previously validated in healthy subjects. Methods: Using auditory-oddball sequences, our approach rests on detecting known attentional modulations of Event Related Potentials that reflect compliance with verbal instructions. Sixty-eight unresponsive patients were tested in their first year after coma onset (37 coma and 31 first year post-coma patients). Their evolution 6 months after the test was considered. Results: Fourteen of the 68 patients, showed a positive response. Nine were in a coma and 5 in a minimally conscious state (MCS). Except for one who died early, all responders evolved to exit-MCS within 6 months (93%), while 35 (65%) among non-responders only. Conclusions: Among those patients for whom the outcome is highly uncertain, 21% responded positively to this simple but cognitively demanding test. Strikingly, some coma patients were among responders. Significance: The proposed paradigm revealed cognitive-motor dissociation in some coma patients. This ability to sustain attention on demand predicted awakening within 6 months and represents an immediately useful information for relatives and caregivers. (c) 2022 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.