Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
JAMA Neurol. 2018 Apr 1;75(4):436-443. doi: 10.1001/jamaneurol.2017.4618.
Preventing delayed neurological sequelae is a major goal of treating acute carbon monoxide poisoning, but to our knowledge there are no reliable tools for assessing the probability of these sequelae.
To determine whether acute brain lesions on diffusion-weighted imaging are related to subsequent development of delayed neurological sequelae after acute carbon monoxide poisoning.
DESIGN, SETTING, AND PARTICIPANTS: This registry-based observational study was conducted at a university hospital in Seoul, Korea, between April 1, 2011, and December 31, 2015. Of 700 patients (aged ≥18 years) with acute carbon monoxide poisoning, 433 patients (61.9%) who underwent diffusion-weighted imaging at an emergency department were considered for the study. Patients who developed cardiac arrest before diffusion-weighted imaging (n = 3), had persistent neurological symptoms at discharge (n = 8), committed suicide soon after discharge (n = 1), and were lost to follow-up (n = 34) were excluded.
The presence of unambiguous, high-signal-intensity, acute brain lesions on diffusion-weighted imaging (b = 1000 s/mm2).
Development of delayed neurological sequelae defined as any neurological symptoms or signs that newly developed within 6 weeks of discharge.
Of the 387 included patients (143 women [37.0%]; median age, 42.0 years [interquartile range, 32.0-56.0 years]), acute brain lesions on diffusion-weighted imaging were observed in 104 patients (26.9%). Among these, 77 patients (19.9%) had globus pallidus lesions, 13 (3.4%) had diffuse lesions, and 57 (14.7%) had focal lesions (37 patients [9.6%] had >1 pattern concurrently). Lesions were supratentorial and infratentorial in 101 and 23 patients, respectively. Delayed neurological sequelae occurred in 101 patients (26.1%). Multivariable logistic regression analysis indicated that the presence of acute brain lesions was independently associated with development of delayed neurological sequelae (adjusted odds ratio, 13.93; 95% CI, 7.16-27.11; P < .001). The sensitivity and specificity of acute brain lesions to assess the probability of delayed neurological sequelae were 75.2% (95% CI, 66.8%-83.7%) and 90.2% (95% CI, 86.8%-93.7%), respectively. In addition, the positive and negative predictive values were 73.1% (95% CI, 64.6%-81.6%) and 91.2% (95% CI, 87.9%-94.5%), respectively.
The presence of acute brain lesions was significantly associated with the development of delayed neurological sequelae. Diffusion-weighted imaging during the acute phase of carbon monoxide poisoning may therefore help identify patients at risk of developing these debilitating sequelae.
预防迟发性神经后遗症是治疗急性一氧化碳中毒的主要目标，但据我们所知，目前尚无可靠的工具来评估这些后遗症发生的概率。
确定急性一氧化碳中毒后扩散加权成像上的急性脑损伤是否与随后发生迟发性神经后遗症有关。
设计、地点和参与者：这是一项基于登记的观察性研究，在韩国首尔的一家大学医院进行，时间为 2011 年 4 月 1 日至 2015 年 12 月 31 日。在 700 名急性一氧化碳中毒患者（年龄≥18 岁）中，考虑纳入了 433 名在急诊科进行扩散加权成像的患者（n=433）。排除了扩散加权成像前发生心脏骤停的患者（n=3）、出院时持续存在神经症状的患者（n=8）、出院后不久自杀的患者（n=1）以及失访的患者（n=34）。
扩散加权成像上存在明确的、高信号强度的急性脑损伤（b 值=1000 s/mm2）。
迟发性神经后遗症的发生定义为出院后 6 周内新出现的任何神经症状或体征。
在纳入的 387 名患者中（143 名女性[37.0%]；中位年龄 42.0 岁[四分位间距 32.0-56.0 岁]），104 名患者（26.9%）存在扩散加权成像上的急性脑损伤。其中，77 名患者（19.9%）存在苍白球病变，13 名患者（3.4%）存在弥漫性病变，57 名患者（14.7%）存在局灶性病变（37 名患者[9.6%]同时存在≥1 种病变模式）。病变位于幕上和幕下的患者分别为 101 名和 23 名。101 名患者（26.1%）发生了迟发性神经后遗症。多变量逻辑回归分析表明，存在急性脑损伤与迟发性神经后遗症的发生独立相关（调整后优势比，13.93；95%CI，7.16-27.11；P<0.001）。急性脑损伤评估迟发性神经后遗症的概率的灵敏度和特异度分别为 75.2%（95%CI，66.8%-83.7%）和 90.2%（95%CI，86.8%-93.7%）。此外，阳性预测值和阴性预测值分别为 73.1%（95%CI，64.6%-81.6%）和 91.2%（95%CI，87.9%-94.5%）。
急性脑损伤的存在与迟发性神经后遗症的发生显著相关。因此，一氧化碳中毒急性期的扩散加权成像可能有助于识别发生这些使人衰弱的后遗症的风险患者。
