Severe hypotension but not systemic inflammation or endothelial activation predicts encephalopathy in circulatory shock - 19/02/26

Doi : 10.1016/j.aicoj.2026.100033

Duc Nam Nguyen ^a,⁎ , Luc Huyghens ^b, Truc Mai Nguyen ^c, Johan Schiettecatte ^d, Marc Diltoer ^a, Wilfried Cools ^e, Helene De Cuyper ^a, David Rhapsorski ^a, Johan Smitz ^d, Haibo Zhang ^f

^a Department of Critical Care Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium

^b Brain Resuscitation in Neurosciences Research Group, Faculty of Medicine, Vrije Universiteit Brussel, Brussels, Belgium

^c Department of Cardiology, University Hospital Vaudois, Lausanne, Switzerland

^d Department of Immunochemistry, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium

^e Department of Biostatistics, Vrije Universiteit Brussel, Brussels, Belgium

^f Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Unity Health Toronto, Department of Anesthesiology and Pain Medicine, Department of Physiology, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Ontario, Canada

^⁎ Corresponding author.

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Graphical abstract

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Abstract

Background

Encephalopathy is a frequent complication of circulatory shock and is associated with adverse outcomes. Whether encephalopathy is driven primarily by systemic inflammation, endothelial activation or cerebral hypoperfusion remains uncertain.

Methods

We retrospectively studied 198 intensive care unit (ICU) patients with circulatory shock (95 septic shock, 103 non-septic shock). Encephalopathy (coma and delirium) was assessed using the Glasgow Coma Scale, Richmond Agitation-Sedation Scale, and Confusion Assessment Method for the ICU. Neuroinflammation or blood-brain barrier (BBB) dysfunction was evaluated using serum S100B protein. Systemic inflammation and endothelial activation were assessed using serum C-reactive protein (CRP), Matrix metalloproteinase-9 (MMP-9), Intercellular Adhesion Molecule -1 (ICAM-1) and Vascular Endothelial Growth Factor (VEGF). Severe hypotension was defined a priori as mean arterial pressure (MAP) <50 mmHg sustained ≥1 min; we also quantified the number of episodes and cumulative duration of MAP <60 and <50 mmHg across the first 72 h. Multivariable logistic regression and mixed-effect models examined associations with encephalopathy and ICU outcomes.

Results

Encephalopathy developed in 140 patients (71%): 31 (23%) with coma and 99 (71%) with delirium. Severe hypotension (OR: 2.56 (1.18, 4.75), p = 0.022), longer sedation duration (OR: 1.09 (1.02, 1.18), p = 0.017), ICU-acquired infections (OR: 1.61(0.73, 3.54), p = 0.021), and elevated S100B (OR: 1.72 (0.66, 3.65), p = 0.03) were associated with encephalopathy. In contrast, systemic inflammation (CRP, MMP-9) and endothelial activation (ICAM-1, VEGF) were not associated with encephalopathy. Despite higher systemic inflammation in septic shock, the prevalence of encephalopathy and structural brain injury was similar to non-septic shock.

Conclusions

In circulatory shock, encephalopathy is most strongly associated with recurrent/severe hypotension (MAP <50 mmHg) and markers of neuroinflammation, not systemic inflammation or endothelial activation.

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Keywords : Encephalopathy, Circulatory shock, S100B protein, Hypotension, Inflammation, Endothelial activation

Abbreviations : APACHE, BBB, CAM-ICU, CI, CRP, CT, CS, ECMO, GCS, HS, IABP, ICAM-1, ICU, MAP, MRI, MMP-9, NIRS, NS, OR, OS, RASS, SOFA, S100B, SCAI, SS, TCD, VEGF