Acute and Critical Care

Articles in E-pub version are posted online ahead of regular printed publication.

Original Articles

Neurology
Effectiveness of intravenous thrombolysis in patients with large-vessel occlusion receiving endovascular treatment in Korea: Min Kim, Ji Sung Lee, Seong-Joon Lee, So Young Park, Jungyun Seo, Ji Man Hong, Hee-Kwon Park, Jae-Kwan Cha, Jeffrey L. Saver, Jin Soo Lee; Received November 7, 2024 Accepted February 19, 2025 Published online April 11, 2025; DOI: https://doi.org/10.4266/acc.004248 [Epub ahead of print]

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Abstract PDF Supplementary Material: Background
The effectiveness of intravenous tissue plasminogen activator (IV tPA) in patients with large-vessel occlusion (LVO) receiving endovascular treatment (EVT) for acute ischemic stroke (AIS) has been questioned. We investigated IV tPA effectiveness in real-world AIS patients, including those with intracranial LVO receiving EVT.
Methods
We identified patients with AIS who presented to hospital with National Institutes of Health Stroke Scale ≥4 within 8 hours of symptom onset from the institutional stroke registry. The association of IV tPA use with effectiveness and safety outcomes was analyzed in overall enrolled AIS patients; LVO patients; and patients treated with EVT. The effect of IV tPA was assessed using multiple logistic regression.
Results
Among the 654 patients meeting study entry criteria, 238 (36.4%) received IV tPA and 416 (63.6%) did not. Multiple logistic regression analysis and shift analysis revealed IV tPA was associated with improved outcomes in overall enrolled AIS population, LVO, and EVT-treated subgroups. Among EVT-treated patients, IV tPA was associated with higher likelihood of ambulatory or better outcome (modified Rankin Scale 0–3) with odds ratio of 1.95 (P=0.03).
Conclusions
In this real-world study, IV tPA use was associated with improved outcomes for patients with AIS, including among LVO patients treated and not treated with EVT, in the contemporary mechanical thrombectomy era.

Nursing
Characteristics and associated risk factors of exposure keratopathy among ventilated patients in intensive care units: Sajeda Al-Tamimi, Mohammad Y.N. Saleh, Al-Mutez Gharaibeh, Farah Al-A’mar, Rasmieh Al-Amer; Received September 19, 2024 Accepted January 27, 2025 Published online April 11, 2025; DOI: https://doi.org/10.4266/acc.003648 [Epub ahead of print]

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Abstract PDF: Background
Exposure keratopathy is the most common ocular surface disorder in ventilated patients due to poor eyelid closure, decreased blink reflex, and the inability to produce tears. Healthcare providers in intensive care units (ICUs) play a significant role in preventing exposure keratopathy through appropriate eyelid taping and eye ointments.
Methods
This is a cross-sectional study to describe the characteristics and factors associated with exposure keratopathy in all mechanically ventilated patients admitted to an adult ICU between February and June 2023. Patients were examined for corneal changes using a corneal fluorescein staining test with a cobalt blue filter indirect ophthalmoscope.
Results
Of 156 ventilated patients included in this study, 42.3% had exposure keratopathy, 13.5% had lagophthalmos, and 26.9% of patients had chemosis. For patients with a Glasgow Coma Scale (GCS) score of 3, the odds ratio of exposure keratopathy was 21.47 (95% confidence interval [CI], 2.82–163.05). The use of inotropes increased the odds ratio to 35.55 (95% CI, 3.41–369.90), whereas a hospital stay >7.23 days increased the odds ratio to 43.59 (95% CI, 15.66–1,316.32).
Conclusions
The frequency of exposure keratopathy is high and is underestimated in ventilated patients, with lower GCS and increased hospital length of stay as the main risk factors. Prioritizing eye care in ventilated patients with low GCS scores or prolonged ICU stays is essential to reduce exposure keratopathy.

Basic science and research
Anesthesiological management in endovascular mechanical thrombectomy: a propensity score-matched retrospective analysis in Italy: Antonio Romanelli, Aniello Iovino, Daniele Giuseppe Romano, Antonella Langone, Rosa Napoletano, Giulia Frauenfelder, Flora Minichino, Liliana D’Ambrosio, Miriam Caterino, Raffaele Tortora, Renato Gammaldi, Paolo Barone, Renato Saponiero; Received July 23, 2024 Accepted November 19, 2024 Published online April 11, 2025; DOI: https://doi.org/10.4266/acc.003000 [Epub ahead of print]

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Abstract PDF: Background
Endovascular mechanical thrombectomy (EMT) can be performed with general anesthesia (GA) or using non-GA techniques. Several meta-analyses on the topic have reported discordant main outcomes. The aim of this retrospective single-center study was to analyze the relationship between clinical outcomes and anesthesiological management (GA vs. non-GA) in patients who underwent EMT for acute anterior ischemic stroke (AIS).
Methods
We performed a propensity score-matched (PSM) analysis of patients who underwent EMT for acute AIS from January 2018 to December 2021. For PSM, we chose covariates influencing clinical decisions about anesthesiological management. Comparisons between groups were performed with the chi-square test for categorical variables and Student t-test or the Mann-Whitney U-test for continuous variables as appropriate. The relationships between anesthesiological management and clinical outcomes were analyzed using logistic regression, and results are reported as odds ratios with 95% confidence intervals. A two-sided P-value <0.05 was considered statistically significant.
Results
From 194 observations (78 in the GA group, 116 in the non-GA group), after PSM, we obtained 70 data pairs. Both anesthesiological approaches resulted in similar rates of in-hospital mortality, 90-day functional independence, full recanalization, procedural complications, and intracerebral hemorrhage (ICH). Performing EMT with GA was unrelated to the in-hospital and 90-day death rates, 90-day functional independence, full recanalization rate, procedural complications, and ICH (P>0.05).
Conclusions
Anesthesiological management did not influence clinical outcomes of EMT for acute AIS. Physiological stability during EMT may impact outcomes more significantly than anesthesiological management. Further studies on this topic are needed.

Letter to the Editor

Neurology
Neuroleptic malignant syndrome requiring intensive care unit admission in two patients with SARS-CoV-2 infection in Portugal: Marina Costa, Ana Raquel Covas, Fábio Neves Correia, Sara Bernardo, Pedro Silveira; Received December 4, 2024 Accepted January 28, 2025 Published online March 13, 2025; DOI: https://doi.org/10.4266/acc.004632 [Epub ahead of print]

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