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Introduction: Cerebral vasospasm (CVS) is a complication of aneurysmal subarachnoid hemorrhage (aSAH). Intraventricular milrinone (IVtM) and intravenous milrinone (IVM) have been studied for treatment of CVS. We aimed to determine the effect of milrinone therapy on clinical and transcranial Doppler (TCD) measures of CVS. Methods: We performed a retrospective analysis of patients with aSAH treated with IVtM at a single tertiary center between 2016 and 2018. Patients were treated with IVtM if they had symptomatic CVS or TCD suggestive of critical CVS that persisted despite blood pressure augmentation or endovascular therapies. Nimodipine was given as standard of care. A subset of patients were also treated with IVM, which was dosed in a standard fashion based on Montreal Neurological Institute protocol. We collected demographic data, TCD mean flow velocity and pulsatility index, angiographic data, as well as utilization and frequency of IVtM and IVM. Results: Twenty-eight patients in our cohort had modified Fisher grade 4 (57%) or grade 3 (25%) and median Hunt-Hess score of 3 (IQR 2, 4). Twenty-one of 28 patients were treated with IVtM+IVM. Seven (25%) who received IVtM alone had no significant improvement in TCD velocities or reduction in symptomatic CVS (p=0.611). Patients received between 1 and 30 doses of IVtM. There was no significant improvement with time or with number of IVtM doses IVtM. There was also no significant improvement in TCD velocities of CVS patients nor reduction in symptomatic CVS with IVtM+IVM (p=0.69). The number of IVtM doses correlated with an increased discharge mRS (p=0.05). There were no direct complications due to IVtM or IVM. Conclusion: Neither IVtM+IVM nor IVtM alone appear to be effective treatment of CVS in aSAH. Our data represent one of the first case series reporting IVtM and IVtM+IVM utilization for the treatment of CVS.

Introduction: Patients with intra-parenchymal (IPH) have seizures detected on continuous EEG (cEEG) monitoring, but data that define seizure risk in IPH patients is limited. Methods: A retrospective chart review of 110 consecutive patients that had ICH on CT or MRI imaging and cEEG monitoring from January 2013 to December 2014 was completed. Patients with isolated cerebellar or brainstem hemorrhages were excluded. Primary aim was to examine the incidence of seizures and abnormal EEG patterns in patients with IPH, particularly those patients with deep IPH. Secondary aim was to examine time from EEG placement to first seizure Results: Median age was 73 [IQR 83-60]. 25 (22.73%) of the 110 patients had an abnormal EEG, defined as the presence of periodic lateralized epileptiform discharges (PLEDS) and/or seizures. 40 (36.36%) had subcortical white matter or thalamic or basal ganglia IPH +/- IVH. 5 (12.5%) of these 40 patients had EEG seizures. 66 (60%) patients had cortical IPH +/- IVH. 11 (16.67%) of these 66 patients had seizures. [OR=0.71, CI=0.23 to 2.23, p=0.56]. 4 patients had both deep and cortical IPH and were excluded. A total of 18 (16.36% of the 110) patients had EEG seizures. Of these 18 patients, 5 (27.78%) patients had deep IPH +/- IVH, defined as subcortical white matter, thalamic or basal ganglia IPH. 11 (61.11%) of the 18 had cortical hemorrhage +/- IVH. 2 (10.5 %) additional patients had both cortical and deep IPH. Additionally, of the 25 patients with abnormal EEG, 7(28%) patients had deep IPH +/- IVH 15(60%) of the 25 patients had cortical hemorrhage +/- IVH. Thus 17.5% of patients with deep IPH and 22.7% of patients with cortical IPH had abnormal cEEG.[OR=0.55, CI=0.20 to 1.48, p=0.23]. Average time for EEG placement from admission was 6 hours and 9 minutes. Average time from EEG placement to first seizure was 7 hours and 4 minutes. Discussion: Subcortical IPH is common and can lead to seizure risk. Our results show that a significant portion of the patients with IPH and seizures on cEEG monitoring had subcortical hemorrhages. They accounted for 28% of cases with seizures and abnormal EEG as well as for 13% of all the patients with subcortical ICHs. This data suggests that patients with supratentorial IPH should be evaluated for subclinical seizures.

Background: Patients with intracerebral hemorrhages (ICH) have a higher incidence of seizures. Previous studies have suggested that the location and size of hemorrhage may increase epileptogenicity. We aim to evaluate seizure development risk factors from clinical examination, imaging, and continuous electroencephalography (CEEG) in critically ill patients with ICH. Methods: We reviewed 57 consecutive patients with ICH admitted to a neurocritical intensive care unit over a 24-month period who were monitored on CEEG. Their demographic and examination data, ICH score, Glasgow coma scale (GCS), location of bleed, CEEG patterns, and discharge status were analyzed. Results: Sixteen (28%) patients from our study cohort had seizures at a mean duration of 7.46 hours from CEEG hookup. Fifteen (93%) of those patients had electrographic only seizures. The finding of lateralized periodic discharges (LPDs) was significantly (p=0.019) associated with seizures. Other variables, such as ICH score, size and location of hemorrhage, GCS, mental status, and other CEEG patterns, were not significantly associated with seizures. Conclusion: We found that LPDs were predictive of seizures in ICH patients. CEEG for longer than 24-hours is preferred for detection of seizures as they occurred at a mean later than seven hours and most were without clinical signs.

Background and Purpose— The failure of recent trials to show the effectiveness of acute endovascular stroke therapy (EST) may be because of inadequate patient selection. We implemented a protocol to perform pretreatment MRI on patients with large-vessel occlusion eligible for EST to aid in patient selection. Methods— We retrospectively identified patients with large-vessel occlusion considered for EST from January 2008 to August 2012. Patients before April 30, 2010, were selected based on computed tomography/computed tomography angiography (prehyperacute protocol), whereas patients on or after April 30, 2010, were selected based on computed tomography/computed tomography angiography and MRI (hyperacute MRI protocol). Demographic, clinical features, and outcomes were collected. Univariate and multivariate analyses were performed. Results— We identified 267 patients: 88 patients in prehyperacute MRI period and 179 in hyperacute MRI period. Fewer patients evaluated in the hyperacute MRI period received EST (85 of 88, 96.6% versus 92 of 179, 51.7%; P P =0.01), and when taken for EST (6 of 63, 9.5% versus 17 of 71, 23.9%; P =0.03). On adjusted multivariate analysis, the EST in the hyperacute MRI period was associated with a more favorable outcome (odds ratio, 3.4; 95% confidence interval, 1.1–10.6; P =0.03) and reduced mortality rate (odds ratio, 0.16; 95% confidence interval, 0.03–0.37; P Conclusions— Implementation of hyperacute MRI protocol decreases the number of endovascular stroke interventions by half. Further investigation of MRI use for patient selection is warranted.

INTRODUCTION: Seizures are well-recognized complications of ischemic strokes (IS). The risk of subsequent development of epilepsy has been shown to be 2-4% in acute IS and much higher in remote IS. However, the risk of epilepsy in IS who have nonconvulsive seizures on cEEG is not well characterized. We present here a five-year retrospective study of IS patients who have nonconvulsive seizures on cEEG identifying risk factors for the development of epilepsy. METHODS: We retrospectively reviewed prospectively collected cEEG and clinical data on consecutive patients monitored from January 1, 2007, to December 31, 2011. We identified those patients with cEEG seizures that were secondary to either acute (30 days) ischemic stroke (IS; n=109) and then included in this study only those patients with follow-up encounters. Statistical analyses were performed with JMP 9.0. RESULTS: Sixty-five (41.5% acute IS, 58.5% remote IS) patients met inclusion criteria for this study. All patients were discharged on at least one antiepileptic. Nineteen (29.2%) patients were found to have seizure recurrence (i.e., epilepsy) with 84.2% being remote IS (p=0.0116). Periodic lateralized epileptiform discharges (PLEDs) were seen on cEEG in 21.5% (22.2% acute IS, 21.1% remote IS). 15.8% with PLEDs on initial cEEG developed epilepsy (p=0.74). 33.3% of patients classified as stupor/coma at the time of nonconvulsive seizures were found to have seizure recurrence compared to 24.1% of patients classified as awake/lethargy (p=0.5841). On follow up EEG (mean (SEM) 384.4 (59.1) days), the finding of sharp wave/spike (12.1%) significantly correlated with seizure recurrence (p=0.0175). DISCUSSION: This retrospective study found that patients with remote IS are at a higher risk of developing epilepsy when nonconvulsive seizures are recorded on cEEG in the hospital. Additionally, the finding of sharp waves on follow-up routine EEG further identifies those at risk for recurrence. This study highlights the usefulness of cEEG in patients in patients with acute or remote strokes and provides guidance on utility of follow-up EEG.