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Objective To investigate the factors associated with the long‐term continuation of anti‐seizure medications (ASMs) in acute stroke patients. Methods We performed a retrospective cohort study of stroke patients with concern for acute symptomatic seizures (ASySs) during hospitalization who subsequently visited the poststroke clinic. All patients had continuous EEG (cEEG) monitoring. We generated a multivariable logistic regression model to analyze the factors associated with the primary outcome of continued ASM use after the first poststroke clinic visit. Results A total of 507 patients (43.4% ischemic stroke, 35.7% intracerebral hemorrhage, and 20.9% aneurysmal subarachnoid hemorrhage) were included. Among them, 99 (19.5%) suffered from ASySs, 110 (21.7%) had epileptiform abnormalities (EAs) on cEEG, and 339 (66.9%) had neither. Of the 294 (58%) patients started on ASMs, 171 (33.7%) were discharged on them, and 156 (30.3% of the study population; 53.1% of patients started on ASMs) continued ASMs beyond the first poststroke clinic visit [49.7 (±31.7) days after cEEG]. After adjusting for demographical, stroke‐ and hospitalization‐related variables, the only independent factors associated with the primary outcome were admission to the NICU [Odds ratio (OR) 0.37 (95% CI 0.15–0.9)], the presence of ASySs [OR 20.31(95% CI 9.45–48.43)], and EAs on cEEG [OR 2.26 (95% CI 1.14–4.58)]. Interpretation Almost a third of patients with poststroke ASySs concerns may continue ASMs for the long term, including more than half started on them acutely. Admission to the NICU may lower the odds, and ASySs (convulsive or electrographic) and EAs on cEEG significantly increase the odds of long‐term ASM use.

Objective Recent research has explored the use of continuous EEG (cEEG) monitoring for prognostication of spontaneous cardiac arrest (SCA). However, there is limited literature on the long‐term (post‐hospital discharge) electrographic findings among SCA survivors and their clinical correlates. Our study aims to fill this critical knowledge gap. Methods We retrospectively used our EEG database to identify adults (≥18 years) with SCA history who underwent an outpatient laboratory‐based EEG between 01/01/2011 and 12/31/2018. After electronic medical records (EMR) review, patients with epilepsy history and unclear/poorly documented SCA history were excluded. Outpatient EEGs were reviewed by authors. Acute EEG findings were extracted from the EEG database and EMR. In addition, we extracted data on acute and long‐term neuroimaging findings (CT/MRI), post‐SCA seizures, and anti‐seizure medications (ASM) status. Descriptive analysis and Fisher's exact test were performed. Results We included 32 SCA survivors (50% women; mean age = 52.1 ± 13.6 years) in the study. During a median clinical follow‐up of 28.2 months, 3 patients suffered only clinical seizures, 3 only chronic post‐hypoxic myoclonus, and 5 had both [11 (34.4%) in total]. Interictal epileptiform discharges (IEDs) were noted in one‐third of the patients, which localized to vertex and frontocentral regions in all but one patient. Five (15.6%) of them did not suffer a clinical seizure despite the presence of EAs. Patients who developed epilepsy were significantly more likely to have abnormal neuroimaging findings [10/11 (90.9%)] during the follow‐up compared to the rest of the patients [OR = 25 (95% CI 2.6–>100, P = .002)]. Half of the study cohort was taking ASM at the last follow‐up. Significance Our small study reveals a signature location of IEDs in SCA survivors. Neuroimaging abnormalities seem to be a better indicator of epilepsy development, while EEG may reveal markers of potential epileptogenicity in the absence of clinical seizures. Future, larger studies are needed to confirm our findings.

OBJECTIVE: The aim was to determine the prevalence and risk factors for electrographic seizures and other electroencephalographic (EEG) patterns in patients with Coronavirus disease 2019 (COVID-19) undergoing clinically indicated continuous electroencephalogram (cEEG) monitoring and to assess whether EEG findings are associated with outcomes. METHODS: We identified 197 patients with COVID-19 referred for cEEG at 9 participating centers. Medical records and EEG reports were reviewed retrospectively to determine the incidence of and clinical risk factors for seizures and other epileptiform patterns. Multivariate Cox proportional hazards analysis assessed the relationship between EEG patterns and clinical outcomes. RESULTS: Electrographic seizures were detected in 19 (9.6%) patients, including nonconvulsive status epilepticus (NCSE) in 11 (5.6%). Epileptiform abnormalities (either ictal or interictal) were present in 96 (48.7%). Preceding clinical seizures during hospitalization were associated with both electrographic seizures (36.4% in those with vs 8.1% in those without prior clinical seizures, odds ratio [OR] 6.51, p = 0.01) and NCSE (27.3% vs 4.3%, OR 8.34, p = 0.01). A pre-existing intracranial lesion on neuroimaging was associated with NCSE (14.3% vs 3.7%; OR 4.33, p = 0.02). In multivariate analysis of outcomes, electrographic seizures were an independent predictor of in-hospital mortality (hazard ratio [HR] 4.07 [1.44-11.51], p < 0.01). In competing risks analysis, hospital length of stay increased in the presence of NCSE (30 day proportion discharged with vs without NCSE: HR 0.21 [0.03-0.33] vs 0.43 [0.36-0.49]). INTERPRETATION: This multicenter retrospective cohort study demonstrates that seizures and other epileptiform abnormalities are common in patients with COVID-19 undergoing clinically indicated cEEG and are associated with adverse clinical outcomes. ANN NEUROL 2021;89:872-883.

Background: The emergence of neurologic symptoms after carotid revascularization is not uncommon and typically caused by perioperative ischemic stroke or hyperperfusion. Postoperative vasculopathy, including reversible cerebral vasoconstriction syndrome (RCVS) is a rare complication of carotid intervention and may be an under-identified cause of neurologic deficit after revascularization. We report a case of reversible postoperative vasculopathy following carotid revascularization as well as its management. Case Presentation: A 74 year old right-handed woman presented to the emergency department with sudden onset left arm weakness and episodic shaking while hypotensive. Computed tomography angiography revealed total occlusion of her right internal carotid artery. Transcranial Doppler monitoring demonstrated active embolic events in her right middle cerebral artery raising concern for continued stump embolization. She underwent carotid revascularization with carotid endarterectomy, mechanical thrombectomy, and carotid angioplasty and initially did well postoperatively. On postoperative day 5, she developed a fixed right gaze and left hemiparesis. Computed tomography revealed new right frontal lobe and basal ganglia infarcts, and angiography showed new right internal carotid, middle cerebral, and anterior cerebral artery vasoconstriction consistent with postoperative vasculopathy. Despite treatment with pressure augmentation and vasodilator therapy, her symptoms persisted resulting in left hemiplegia at discharge. Discussion: This case highlights postoperative vasculopathy (including RCVS) as a rare potential complication after carotid revascularization that should be considered in a patient with persistent acute neurologic symptoms. Information regarding incidence and predisposing risk factors is limited. Multiple diagnostic and therapeutic modalities may be necessary in the recognition and treatment of postoperative vasculopathy.

Introduction: SARS-Coronavirus-2 infection leading to COVID-19 disease presents most often with respiratory failure. The systemic inflammatory response of SARS-CoV-2 along with the hypercoagulable state that the infection elicits can lead to acute thrombotic complications including ischemic stroke. We present 3 cases of patients with COVID-19 disease who presented with varying degrees of vascular thrombosis. Cases: Cases 1 and 2 presented as cerebral ischemic strokes without respiratory failure. Given their exposure risks, they were both tested for COVID-19 disease. Case 2 ultimately developed respiratory failure and pulmonary embolism. Cases 2 and 3 were found to have simultaneous arterial and venous thromboembolism (ischemic stroke and pulmonary embolism) as well as positive antiphospholipid antibodies. Conclusion: Our case series highlight the presence of hypercoagulability as an important mechanism in patients with COVID-19 disease with and without respiratory failure. Despite arterial and venous thromboembolic events, antiphospholipid and hypercoagulable panels in the acute phase can be difficult to interpret in the context of acute phase response and utilization of thrombolytics. SARS-CoV-2 testing in patients presenting with stroke symptoms may be useful in communities with a high case burden or patients with a history of exposure.

Introduction Patient-centered care, particularly shared medical decision making, is difficult to measure in critically ill patients where decisions are often made by a designated surrogate, often receiving information from multiple providers with varying degrees of training. The purpose of this study was to compare short-term satisfaction with care and decision making in patients or surrogates between two neurocritical care units [one staffed by a neurocritical care attending and advanced practice providers (APPs) and one staffed by a neurocritical care attending and resident/fellow trainees] using the Family Satisfaction in the ICU (FS-ICU) survey. Methods Over a 6-month period, the FS-ICU was administered on a tablet device to patients or surrogates at least 24 h after admission and stored on REDCap database. Results One hundred and thirty-four patients or surrogates completed the FS-ICU. The response rates were 59.97% and 46.58% in the APP and trainee units, respectively. There were no differences in patient age, sex, ventilator days or ICU length of stay. Overall, there were no differences in satisfaction with care or perceived shared medical making between the units. Respondents who identified their relationship with the patient as “other” (not a spouse, parent, nor a sibling) were less satisfied with care. Additionally, surrogates who identified as parents of the patient were more satisfied with degree of shared medical decision making. Conclusion This study showed that: (1) collecting FS-ICU in a neurocritical care unit is feasible, (2) overall there is no difference in short-term satisfaction with care or shared decision making between a NICU staffed with trainees compared to one staffed with APPs, and (3) parents of patients have a higher short-term satisfaction with degree of shared medical decision making.

BackgroundPostanoxic myoclonus is a known poor prognostic sign, and other postanoxic spontaneous movements have been reported but poorly described. We aim to describe the electroclinical phenomenon of postanoxic eyelid openings in context of its possible prognostic value.MethodsWe collected clinical data on postcardiac arrest patients with suspicious eyelid movements noted on continuous EEG monitoring. The eyelid movements captured on the video were correlated with the EEG findings and final clinical outcome. Neuroimaging data were reviewed when available. We also conducted a thorough literature review on this topic.ResultsA total of 10 patients (5 females) with average age of 56.1 (±14.4) years were included. The mean cardiopulmonary resuscitation duration was 18.9 (±11.3) minutes. Postanoxic eyelid-opening movements occurred at variable intervals (0.5–570 seconds) in each individual. Close examination of eyelid opening (available in 6 patients) revealed them to be tonic movements, lasting an average of 3 (±0.8) seconds and always succeeded the onset of burst of EEG activity in a burst-suppression background. This is a transient phenomenon, lasting a median duration of 30 (interquartile range 7.75–36) hours. MRI findings in 3 patients demonstrated diffuse cortical ischemic injury with relative sparing of the brainstem. All patients died within 2–7 days following cardiac arrest.ConclusionsContrary to previous descriptions, the postanoxic tonic eyelid openings (PATEO) are repetitive but nonperiodic, nonmyoclonic movements. Their close and specific temporal correlation with the burst of EEG activity suggests that this could be considered an ictal phenomenon requiring an intact midbrain based on MRI findings.

Purpose. Seizure is a well-recognized complication of both remote and acute ischemic strokes. Predictors of seizure recurrence and epilepsy in patients with ischemic stroke who develop acute symptomatic seizures (ASyS) on continuous electroencephalography (cEEG) have not been well studied. Methods. We present a five-year retrospective study of acute and remote ischemic stroke patients who developed ASyS on cEEG. We then identified risk factors for the development of seizure recurrence. Results. Sixty-five patients with ischemic stroke and ASyS were identified and reviewed. All ASyS were noted to be nonconvulsive seizures. Clinical recurrence of seizures was identified in 19 of these patients (29.2%) at follow-up. Rate of seizure recurrence was higher in remote ischemic stroke patients (84.2%), compared to acute ischemic stroke patients (15.8%, p=0.0116, OR 0.17, 95% CI 0.049–0.65). Sharp waves/spikes on follow-up EEG significantly correlated with seizure recurrence (p=0.006, OR 0, 95% CI 0–0.3926). Patients discharged on ≥3 antiepileptic drugs (AEDs) were at a higher risk of having seizure recurrence (p=0.0015, OR 0.05, 95% CI 0.0089–0.37). Conclusion. We identified risk factors of seizure recurrence in patients with ASyS as remote ischemic stroke, requiring multiple AEDs, and the presence of sharp waves on follow-up EEG. This study highlights the usefulness of cEEG in evaluating patients with acute or remote strokes.

Reversible cerebral vasoconstriction syndrome (RCVS) is a disorder of dysregulation of cerebrovascular tone resulting in transient segmental vasoconstriction which resolves in 1–3 months. Cerebral edema is an underrecognized complication in RCVS. It is likely multifactorial. This edema can lead to intracranial hypertension that can be refractory to medical management. Limited evidence exists regarding surgical management of intracranial hypertension in RCVS. We present a 29-year-old Caucasian right-handed female patient with a medical history of migraine, polysubstance abuse presented to the emergency department (ED) daily for 3 days with the chief complaint of recurrent thunderclap headache. She declined neuroimaging and lumbar puncture. She was treated for migraine with abortive medications with no improvement. During the third ED visit, she became lethargic with right-sided homonymous hemianopia. Computerized tomography of the brain showed left parietal intracerebral hemorrhage with intraventricular extension, cortical subarachnoid hemorrhage, and diffuse cerebral edema. Digital subtraction angiography showed multifocal moderate-to-severe segmental vasoconstriction suggestive of vasculopathy. Oral verapamil was initiated. Continuous intracranial pressure monitoring showed uncontrolled intracranial hypertension, despite maximal medical management with hyperosmolar therapy, induced coma, and hypothermia. Decompressive hemicraniectomy with duraplasty was performed for refractory intracranial hypertension. We provisionally diagnosed her with RCVS. She was discharged to inpatient rehabilitation with residual right homonymous hemianopia. Transcranial Doppler study during follow-up showed improved mean flow velocities. She continued to have residual cognitive deficits with complete resolution of headache.

Background and Purpose: The association between SARS-CoV-2 infection and stroke remains unknown. We aimed to compare the characteristics of stroke patients who were hospitalized with Coronavirus Disease 2019 (COVID-19) based on the timing of stroke diagnosis. Methods: We performed a retrospective analysis of adult patients in a health system registry of COVID-19 who were hospitalized and had imaging-confirmed acute stroke during hospitalization. Baseline characteristics and hospital outcomes were collected and analyzed. Results: Out of 882 COVID-19 patients who were hospitalized between March 9 to May 17, 2020, 14 patients (2% of all COVID-19 patients and 21% of those who underwent imaging) presented with stroke or developed stroke during hospitalization. Eleven had acute ischemic stroke (AIS) and 3 had acute hemorrhagic stroke. Six patients (43%) presented to the hospital with acute stroke symptoms and were found to have SARS-CoV-2. Compared to patients who presented with AIS, more patients with AIS during hospitalization were male, of older age, had pneumonia and acute respiratory distress syndrome, were severely ill, and had high inflammatory and thrombotic markers (including C reactive protein, D dimer, ferritin, and fibrinogen). Among all patients, hospital mortality was high (50%) and the majority of patients who were discharged had poor neurological outcome. Conclusions: A distinction should be made between patients who present with acute stroke with concurrent SARS-CoV-2 infection and those who develop stroke as a complication of severe COVID-19. It is likely that a subset of stroke patients will incidentally test positive for the virus given the widespread pandemic.

Highlights • We present a report on continuous EEG (cEEG) findings in COVID-19 patients. • cEEG revealed findings consistent with encephalopathy independent of IV anesthetics. • Acute symptomatic seizures were noted in two patients., Objective As concerns regarding neurological manifestations in COVID-19 (coronavirus disease 2019) patients increase, limited data exists on continuous electroencephalography (cEEG) findings in these patients. We present a retrospective cohort study of cEEG monitoring in COVID-19 patients to better explore this knowledge gap. Methods Among 22 COVID-19 patients, 19 underwent cEEGs, and 3 underwent routine EEGs (

BackgroundNeurological manifestations of COVID-19 have only recently been described, with a paucity of literature reporting the potential relationship between COVID-19 and acute symptomatic seizures. Two prior studies found no clinical or electrographic seizures in their cohorts of COVID-19 patients with altered mental status (AMS) and clinical seizure-like events (SLEs).MethodsIn this retrospective cohort study, 22 critically-ill COVID-19 patients above the age of 18 years who underwent EEG (electroencephalography) monitoring between April 20th, 2020 and May 20th, 2020 were studied. 19 patients underwent continuous EEG (cEEG) for at least 24 hours, and 3 patients underwent routine EEGs (Findings17 patients underwent EEG monitoring for unexplained altered mental status changes and 5 patients underwent monitoring for a seizure-like event. 5 patients had epileptiform abnormalities on EEG (4 patients on cEEG, 1 on routine EEG); and only 2 of 5 epileptic EEG patients had a prior history of epilepsy. 2 patients in our cohort had electrographic seizures in the absence of prior epilepsy history. No patients with epileptiform abnormalities or electrographic seizures had acutely abnormal neuroimaging on CT or MRI.InterpretationEncephalopathic COVID-19 positive patients had a range of EEG abnormalities, and a higher proportion of patients in this series had electrographic seizures than previous literature suggests. This may be influenced by the duration of monitoring with cEEG and the use of a 21 channel electrode system. cEEG findings may help to guide antiseizure medical therapy, as well as the workup of altered mental status in the setting of unremarkable neuroimaging.FundingNo funding was used for this study.

Background The coronavirus disease of 2019 (COVID-19) emerged as a global pandemic. Historically, the group of human coronaviruses can also affect the central nervous system leading to neurological symptoms; however, the causative mechanisms of the neurological manifestations of COVID-19 disease are not well known. Seizures have not been directly reported as a part of COVID-19 outside of patients with previously known brain injury or epilepsy. We report two cases of acute symptomatic seizures, in non-epileptic patients, associated with severe COVID-19 disease. Case Presentations Two advanced-age, non-epileptic, male patients presented to our northeast Ohio-based health system with concern for infection in Mid-March 2020. Both had a history of lung disease and during their hospitalization tested positive for SARS-CoV-2. They developed acute encephalopathy days into their hospitalization with clinical and electrographic seizures. Resolution of seizures was achieved with levetiracetam. Discussion Patients with COVID-19 disease are at an elevated risk for seizures, and the mechanism of these seizures is likely multifactorial. Clinical (motor) seizures may not be readily detected in this population due to the expansive utilization of sedatives and paralytics for respiratory optimization strategies. Many of these patients are also not electrographically monitored for seizures due to limited resources, multifactorial risk for acute encephalopathy, and the risk of cross-contamination. Previously, several neurological symptoms were seen in patients with more advanced COVID-19 disease, and these were thought to be secondary to multi-system organ failure and/or disseminated intravascular coagulopathy-related brain injury. However, these patients may also have an advanced breakdown of the blood–brain barrier precipitated by pro-inflammatory cytokine reactions. The neurotropic effect and neuroinvasiveness of SARS-Coronavirus-2 have not been directly established. Conclusions Acute symptomatic seizures are possible in patients with COVID-19 disease. These seizures are likely multifactorial in origin, including cortical irritation due to blood–brain barrier breakdown, precipitated by the cytokine reaction as a part of the viral infection. Patients with clinical signs of seizures or otherwise unexplained encephalopathy may benefit from electroencephalography monitoring and/or empiric anti-epileptic therapy. Further studies are needed to elucidate the risk of seizures and benefit of monitoring in this population.

Purpose: Acute symptomatic seizures (ASyS) are common in critically ill patients. It is unknown how ASyS affect posthospitalization self-reported health compared to patients with established epilepsy. Methods: This is a retrospective cohort study from 2010 to 2018. Patients were identified by an institutional epilepsy database (Ebase). Patient-reported outcome measures (PROMs) were completed as part of standard of care and included the number of seizures in the prior 4 weeks, Liverpool Seizure Severity Scale (LSSS) ictal score, quality of life in epilepsy (QOLIE)-10, Patient Health Questionnaire-9 scales, and the PROM Information System Global Health (PROMIS-GH) scale. Mixed-effects models were created to adjust for age, sex, and race and to examine score trajectory over the 1 year after baseline. Results: A total of 15 311 established epilepsy patients and 317 patients with ASyS were identified. When compared to patients with epilepsy, patients with ASyS were older, mostly male, more often black, and had worse baseline scores on the QOLIE-10 ( P < .001), PROMIS-GH Physical Health ( P = .037), and LSSS Ictal ( P = .006) scales. Patient-Reported Outcomes Measurement Information System Mental and Physical Health T-scores were worse than the general population (T-score = 50) for patients with both ASyS (44 and 42.5, respectively) and epilepsy (44.2 and 44.6, respectively). After adjusting for age, sex, and race, patients with ASyS reported 38% fewer seizures ( P = .006) yet worse QOLIE-10 score ( P = .034). We found that scores improved over time for all PROMs except for PROMIS-GH Mental Health. Conclusion: Compared to patients with epilepsy, patients with ASyS had fewer seizures but worse epilepsy-specific quality of life. Independent of group status, scores generally improved over time.

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.

ObjectivesTo compare the degrees to which 8 domains of health are affected across types of cerebrovascular events and to identify factors associated with domain scores in different event types.MethodsThis was an observational cohort study of 2,181 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or TIA in a cerebrovascular clinic from February 17, 2015, to June 2, 2017 who completed Quality of Life in Neurologic Disorders executive function and the following Patient-Reported Outcomes Measurement Information System scales as part of routine care: physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance.ResultsAll health domains were affected to similar degrees in patients with ICH, SAH, and ischemic stroke after adjustment for disability and other clinical factors, whereas patients with TIA had worse adjusted scores for 5 of the 8 domains of health. Female sex, younger age, lower income, and event ConclusionsThe subtype of stroke (ischemic stroke, ICH, and SAH) had similar effects in multiple health domains, while patients with TIA had worse adjusted outcomes, suggesting that the mechanisms for outcomes after TIA may differ from those of other cerebrovascular events. The most affected domains across all event types were physical function, satisfaction with social roles, and executive function, highlighting the need to develop effective interventions to improve these health domains in survivors of these cerebrovascular events.

Objective To evaluate the incidence of new onset epilepsy and associated risk factors in patients with periodic patterns on continuous electroencephalography (cEEG) during critical illness. Methods The local cEEG database and then medical records were reviewed from January 1, 2013 to June 30, 2013 to find adult patients with no history of epilepsy who had periodic discharges-either lateralized (LPDs) or generalized (GPDs)-or nonperiodic/nonepileptogenic (NP/NE) findings on cEEG and ≥3 months of clinical follow-up. Clinical seizure after discharge was the primary outcome. Chi-square test, Kruskal-Wallis test, and Cox proportional hazards models were used for statistical analysis. Results A total of 195 patients (median age = 67.8 years) were included. There were 53 (27%), 73 (37%), and 69 (35%) patients with LPDs, GPDs, and NP/NE findings on cEEG, respectively. These three groups did not differ by demographic or clinical variables. A total of 29 (15%) patients (LPDs = 20 [38%], GPDs = 4 [6%], and NP/NE = 5 [7%]) developed epilepsy during a median follow-up of 32.1 (95% confidence interval [CI] = 13.2-42.8) months. The hazard ratio for epilepsy development among LPD patients was 7.7 (95% CI = 2.9-20.7) times compared to the NP/NE group, and the risk further increased to 11.4 (95% CI = 4-31.4) times if they also had electrographic seizures. This association remained significant despite adjusting for each covariate at a time. Significance Patients with LPDs on cEEG during critical illness are at least seven times more likely to develop epilepsy compared to patients with NP/NE findings. This risk is further increased if patients with LPDs have electrographic seizures. In comparison, the presence of GPDs does not seem to impact the risk for developing epilepsy. cEEG findings at the time of acute insult have potential to serve as prognostic biomarkers for epilepsy development.

Purpose Electrographic seizures detected by continuous electroencephalography (CEEG) in critically ill patients with altered mental status is becoming increasingly recognized. Data guiding the appropriate selection of patients to be monitored on CEEG are lacking. The aims of this article were to study the incidence of seizures in the critical care setting and to evaluate for clinical predictors to improve the efficiency of CEEG monitoring. Methods Retrospective review of the CEEG and clinical data on 1,123 consecutive patients who had continuous video EEG over a 24-month period. Results Seizures were recorded in 215 patients on CEEG monitoring (19.1%). In total, 89.3% of these seizures occurred without clinical signs. Patients who were in a coma were more likely to have EEG seizures (odds ratio, 3.64; 95% confidence interval, 2.23-5.95) compared with those awake. The incidence of seizures was overrepresented in patients with extra-axial tumors (41.9%), multiple sclerosis (35.7%), and intra-axial tumors (33.0%). Lateralized periodic discharges were predictive (odds ratio, 8.27; 95% confidence interval, 5.52-12.46) of seizure occurrence compared with those with no epileptiform patterns. Only generalized periodic discharges with triphasic morphology had no increased odds of seizure (odds ratio, 1.02; 95% confidence interval, 0.24-3.03). When present, electroencephalography seizures were detected within 24 hours in 92% of monitored patients. Conclusions Continuous electroencephalography monitoring in the critical care setting demonstrates a linear increase in seizure incidence with declining mental status. Recognizing clinical conditions and electroencephalography markings may help in the appropriate selection of critically ill patients for CEEG monitoring.

Intracranial hemorrhage (ICH) is associated with significant mortality and morbidity. Current treatment paradigms focus on correcting hypertension and coagulopathy to prevent hematoma expansion. Magnetic resonance imaging (MRI) is becoming more common in the hyperactive phase of ICH management. The finding of contrast extravasation (ie, spot sign) on MRI may be a marker of active bleeding. We present a case of MRI spot sign and review of the literature.We present a patient on oral coumadin for history of deep venous thrombosis and pulmonary embolus who presented with a right basal ganglia hemorrhage. She had a computed tomography angiography showing contrast extravasation and also had a hyperacute MRI showing similar contrast extravasation. Follow-up imaging showed hematoma enlargement.We present here a case of corroboration of the computed tomography angiography spot sign with the MRI spot sign. The prognostic value of the MRI spot sign is unclear. Future studies should evaluate the prognostic value of the hyperacute MRI in ICH management.

Reversible cerebral vasoconstriction syndrome (RCVS) is a clinicoradiological syndrome that occurs due to dysfunction of cerebrovascular autoregulation. It is characterized by recurrent thunderclap headache from cerebral vasoconstriction which can cause ischemic infarction, spontaneous intraparenchymal and subarachnoid hemorrhage. This syndrome can be triggered by a variety of etiologies including medications, infectious, and inflammatory conditions. The diagnosis is often delayed due to unawareness among the health-care providers and delayed neuroimaging evidence of vasoconstriction with or without ischemic and/or hemorrhagic infarction. Status migrainosus is a prevalent condition requiring emergency room visits and inpatient admission. Thus, patients with RCVS can be easily misdiagnosed with migraine. We report a patient with RCVS misdiagnosed as status migrainosus with visual aura, treated with intravenous dihydroergotamine with worsening of cerebral vasoconstriction and lead to ischemic and hemorrhagic complications. We discuss this complication and provide guidance on differentiating between migraine and RCVS.

Central venous catheter (CVC) insertion is extensively utilized in Intensive Care Units for evaluation of hemodynamic status, administration of intravenous drugs, and for providing nutritional support in critically ill patients. Unfortunately, CVC use is associated with complications including lung injury, bleeding, infection, and thrombosis. We present a patient with an acute ischemic stroke from an inadvertently placed CVC into the right common carotid artery. A 57-year-old male presented to our institution for left hemiplegia and seizures 2 days after a CVC was placed. He was found to have a right frontal ischemic stroke on computed tomography (CT). CT angiography noted that the catheter was arterial and had a thrombosis around it. He was started on a low-dose heparin infusion. A combination of cardiothoracic surgery and interventional cardiology was required to safely remove the catheter. Central arterial catheterization is an unusual cause for acute ischemic stroke and presents management challenges.

Fever increases mortality and morbidity and length of stay in neurocritically ill patients. Various methods are used in the neuroscience intensive care unit (NSICU) to control fever. Two such methods involve the Arctic Sun hydrogel wraps and the Gaymar cooling wraps. The purpose of our study was to compare these two methods in neurocritical care patients who had temperature37.5°C for more than three consecutive hours and that was refractory to standard treatments. Data of patients requiring cooling wraps for treatment of hyperthermia at an NSICU at an academic, tertiary referral center were retrospectively reviewed. The average temperature before cooling was 38.5°C ± 0.38°C and 38.4°C ± 0.99°C for the Gaymar and Arctic Sun groups, respectively (p = 0.89). The Gaymar group took on average 16 ± 21.9 hours to reach goal temperature, whereas the Arctic Sun group took 2.22 ± 1.39 hours (p = 0.08). The average time outside of the target temperature was 57.0 ± 58.0 hours in the Gaymar group compared with 13.7 ± 17.1 hours in the Arctic Sun group (p = 0.04). Average duration of using the cooling wraps was similar between the two groups; 81.8% of patients had rebound hyperthermia in the Gaymar group compared with 20% in the Arctic Sun group (p = 0.0089). The Arctic Sun group had a nonsignificant increased incidence of shivering compared with the Gaymar group (40% vs. 18.18%, p = 0.36). We found that Arctic Sun surface cooling device was more efficient in attaining the target temperature, had less incidence of rebound hyperthermia, and was able to maintain normothermia better than Gaymar cooling wraps. The incidence of shivering tended to be more common in the Arctic Sun group.

Neurological complications in liver failure are common. Often under-recognized neurological complications are seizures and status epilepticus. These may go unrecognized without continuous electroencephalography (CEEG). We highlight the observed electro-radiological changes in patients with grade III/IV hepatic encephalopathy (HE) found to have seizures and/or status epilepticus on CEEG and the associated neuroimaging. This study was a retrospective review of patients with West Haven grade III/IV HE and seizures/status epilepticus on CEEG. Eleven patients were included. Alcohol was the most common cause of HE (54.5%). All patients were either stuporous/comatose. The most common CEEG pattern was diffuse slowing (100%) followed by generalized periodic discharges (GPDs; 36.4%) and lateralized periodic discharges (LPDs, 36.4%). The subtype of GPDs with triphasic morphology was only seen in 27.3%. All seizures and/or status epilepticus were without clinical signs. Magnetic resonance imaging (MRI) was available in six patients. Cortical hyperintensities on diffusion weighted imaging sequence were seen in all six patients. One patient had CEEG seizure concomitantly with the MRI. Seven patients died prior to discharge. Seizures or status epilepticus in the setting of HE were without clinical findings and could go unrecognized without CEEG. The finding of cortical hyperintensity on MRI should lead to further evaluation for unrecognized seizure or status epilepticus.

Purpose To risk-stratify electrographic features of lateralized periodic discharges (LPDs) in acute structural brain lesions for predictors of electrographic seizures. Methods This is a retrospective review of 100 consecutive patients with LPDs. Epileptiform features of LPDs were described based on electrographic features: blunt delta morphology, sharply contoured, overlying fast frequencies, and/or rhythmicity (loss of interdischarge interval lasting ≥1 second). EEG seizures were defined as evolving in frequency, distribution, or morphology at ≥2 Hz for ≥10 seconds. Results Overall, electrographic seizures occurred in 55% of patients with LPDs. Lateralized periodic discharges with rhythmicity (odds ratio 13.91) were most significant for predicting status epilepticus and/or seizures. This was followed by LPDs with overlying faster frequencies (odds ratio 5.16) and then sharply contoured morphology (odds ratio 4.09). Blunt delta morphology (0.24) had the lowest risk for seizures. Conclusions Electrographic features of LPDs may help determine seizure risk in patients with acute structural lesions. Sharply contoured morphology, overlying fast frequencies, or rhythmicity, showed progressively higher risk of seizures on continuous electroencephalography, whereas blunt delta morphology had the lowest risk of seizures.

Delaying extubation in neurologically impaired patients otherwise ready for extubation is a source for significant morbidity, mortality, and costs. There is no consensus to suggest one spontaneous breathing trial (SBT) over another in predicting extubation success. We studied an algorithm using zero pressure support and zero positive end-expiratory pressure (ZEEP) SBT followed by 5-cm H2O pressure support and 5-cm H2O positive end-expiratory pressure (i.e., 5/5) SBT in those who failed ZEEP SBT. This is a retrospective analysis of intubated patients in a neurosciences intensive care unit. All eligible patients were initially challenged with ZEEP SBT. If failed, a 5/5 SBT was immediately performed. If passed either the ZEEP SBT or the subsequent 5/5 SBT, patients were liberated from mechanical ventilation. In total, 108 adult patients were included. The majority of patients were successfully liberated from mechanical ventilation using ZEEP SBT alone (82.4%; p = 0.0007). Fifteen (13.8%) patients failed ZEEP SBT but immediately passed 5/5 SBT (p = 0.0005). One patient (0.93%) required reintubation. We found high sensitivity of this extubation algorithm (100; 95% CI 95.94–100%) but poor specificity (6.67; 95% CI 0.17–31.95%). This study showed that the majority of patients could be successfully liberated from mechanical ventilation after a ZEEP SBT. In those who failed, a 5/5 SBT increased the successful liberation from mechanical ventilation.

Introduction: High-fidelity simulation is frequently utilized in medical education. Its use in the neurosciences is limited by the inherent limitations of the manikin to simulate neurological changes. We report here the use of a hybrid simulation – a combination of lecture and high-fidelity manikin – in the education of neurosciences nurses, involved in care of neurocritical care patients. Methods: Neurosciences nurses from at the University of Missouri, Columbia, MO, USA, which is an academic, tertiary-care medical center participated in the simulation during Spring of 2016. The simulation involved a patient presenting with acute intracerebral hemorrhage (ICH) who neurologically deteriorated to brain death. Pre- and post-simulation questionnaires were administered using a questionnaire with five-point Liker scale. Results: Seventy-two responses were returned. The majority had 0-5 years of nursing experience with 83.8% having prior critical care experience. Pre-simulation, the majority of nurses (85.7%) agreed or strongly agreed with managing patients with ICH. When the responses of “agree” were compared to “strongly agree”, a significant improvement (p

Objective We present a model for the outpatient care of patients undergoing continuous electroencephalography (cEEG) monitoring during a hospitalization, named the post‐acute symptomatic seizure (PASS) clinic. We investigated whether establishing this clinic led to improved access to epileptologist care. Methods As part of the PASS clinic initiative, electronic health record (EHR) provides an automated alert to the inpatient care team discharging adults on first time antiepileptic drug (AED) after undergoing cEEG monitoring. The alert explains the rationale and facilitates scheduling for a PASS clinic appointment, three‐month after discharge, along with a same‐day extended (75 minutes) EEG. We compared the initial epilepsy clinic visits by patients undergoing cEEG in 2017, before (“Pre‐PASS” period and cohort) and after (“PASS” period and cohort) the alert went live in the EHR. Results Of the 170 patients included, 68 (40%) suffered a seizure during the mean follow‐up of 20.9 ± 10 months. AEDs were stopped or reduced in 66 out of 148 (44.6%) patients discharged on AEDs. Pre‐PASS cohort included 45 patients compared to 145 patients in the PASS cohort, accounting for 5.8% and 9.9% of patients, respectively, who underwent cEEG during the corresponding periods (odds ratio [OR] = 1.8, 95% CI = 1.26‐2.54, P = .001). The two cohorts did not differ in terms of electrographic or clinical seizures. The PASS cohort was significantly more likely to be followed up within 1‐6 months of discharge (OR = 4.6, 95% CI = 2.1‐10.1, P

Introduction. Acute symptomatic seizures are frequent in the critically ill patient and can be difficult to treat. The novel anticonvulsant perampanel may be effective in the treatment of status epilepticus considering its mechanism of action of being an AMPA antagonist. We present four cases of super refractory status epilepticus treated with high dose perampanel. Method. Case report. Cases. Four patients were treated with perampanel for their refractory status epilepticus. One patient had new onset refractory status epilepticus of unknown etiology. Three other patients had status epilepticus as a result of their cardiac arrest. Two of the cardiac arrest patients had myoclonus. In all patients, the additional of perampanel resulted in a reduction of seizure burden without affecting hemodynamics or hepatic or renal function. Conclusion. Perampanel may be effective in the treatment of super-refractory status epilepticus of varying etiologies. A larger, prospective study is needed to further assess this therapy.

Objective This study was designed to investigate if highly epileptic electroencephalogram (EEG) findings in patients with acute brain injury increase the long‐term risk of epilepsy development. Methods Adults patients, lacking epilepsy history, with electrographic seizures or lateralized periodic discharges (LPDs) (cases) were identified and matched based on age, mental status, and etiology with the ones lacking any epileptiform activity (controls) on continuous EEG (cEEG) during hospitalization. The primary outcome of clinical seizures after hospital discharge and their antiepileptic drug (AED) status was determined using a telephonic interview. Logistic regression models using generalized estimating equations to account for the matched nature of the data were performed. Results A total of 70 cases [16 (22.9%) “LPDs only,” 34 (48.6%) “electrographic seizure only,” and 20 (28.6%) “both”] and controls were enrolled. A total of 22 (31.4%) cases developed epilepsy after a mean follow‐up duration of 20.6 ± 5.0 months compared to three (4.3%) controls. After adjusting for cEEG indication and follow‐up duration, the odds of cases developing epilepsy were almost 15 times higher compared to the controls (OR = 14.8, 95% CI = 2.4–92.3, P = 0.004). This elevated risk was despite a 10 times higher likelihood of cases to be taking AEDs at the last follow‐up (OR = 10.34, 95% CI = 3.7–29, P

Anti-N-methyl-D-aspartate (NMDA) encephalitis is an autoimmune-mediated process characterized by psychosis, seizures, dyskinetic movements, and autonomic instability. At least half of the reported cases are paraneoplastic, particularly associated with an ovarian teratoma. None have been reported to be associated with thyroid tumor. We present a case of anti-NMDA encephalitis concomitantly occurring in setting of papillary thyroid carcinoma in a woman who presented with headaches, myalgia and somnolence mimicking meningoencephalitis. A 29-year-old African female presented with fever, headache, myalgia, somnolence and behavioral changes. Initial evaluation was significant for lymphocytic pleocytosis with normal glucose and protein. She was started on broad spectrum empiric antibiotics. Despite antibiotics, she continued to have worsening encephalopathy, hallucinations, epileptic seizures, and multifocal dyskinesias involving the face and extremities with no electroencephalogram correlate. Extensive infectious workup was unremarkable. Whole-body CT with contrast and ovarian ultrasound were unremarkable for malignancy. Serum auto-antibodies to the NMDA receptor and thyroid peroxidase were detected. She was treated with high-dose intravenous steroids, plasmapheresis, intravenous immunoglobulin, and rituximab with no clinical or serological response. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed a hypermetabolic thyroid nodule. Fine needle aspiration of the nodule revealed papillary thyroid carcinoma. She underwent total thyroidectomy and pathology showed two foci of tall-cell variant papillary thyroid carcinoma. Serological and clinical response followed shortly after tumor resection. The NMDA receptor stain of the papillary thyroid carcinoma was nonreactive. We describe the coincidentally co-occurrence of NMDA encephalitis in a patient with papillary thyroid carcinoma. This case highlights the importance of presumed cases of non-paraneoplastic NMDA encephalitis, FDG-PET may help in detecting occult malignancies.