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Background and Purpose: Although most strokes present with mild symptoms, these have been poorly represented in clinical trials. The objective of this study is to describe multidimensional outcomes, identify predictors of worse outcomes, and explore the effect of thrombolysis in this population. Methods: This prospective observational study included patients with ischemic stroke or transient ischemic attack, a baseline National Institutes of Health Stroke Scale (NIHSS) score 0 to 5, presenting within 4.5 hours from symptom onset. The primary outcome was a 90-day modified Rankin Scale score of 0 to 1; secondary outcomes included good outcomes in the Barthel Index, Stroke Impact Scale-16, and European Quality of Life. Multivariable models were created to determine predictors of outcomes and the effect of alteplase. Results: A total of 1765 participants were included from 100 Get With The Guidelines-Stroke participating hospitals (age, 65±14; 42% women; final diagnosis of ischemic stroke, 90%; transient ischemic attack, 10%; 57% received alteplase). At 90 days, 37% were disabled and 25% not independent. Worse outcomes were noted for older individuals, women, non-Hispanic Blacks and Hispanics, Medicaid recipients, smokers, those with diabetes, atrial fibrillation, prior stroke, higher baseline NIHSS, visual field defects, and extremity weakness. Similar outcomes were noted for the alteplase-treated and untreated groups. Alteplase-treated patients were younger (64±13 versus 67±1.4) with higher NIHSS (2.9±1.4 versus 1.7±1.4). After adjusting for age, sex, race/ethnicity, and baseline NIHSS, we did not identify an effect of alteplase on the primary outcome but did find an association with Stroke Impact Scale-16 in the restricted sample of baseline NIHSS score 3–5. Few symptomatic intracerebral hemorrhages were recorded ( Conclusions: A large proportion of stroke patients presenting with low NIHSS have a disabled outcome. Baseline predictors of worse outcomes are described. An effect of alteplase on outcomes was not identified in the overall cohort, but a suggestion of efficacy was noted in the NIHSS 3–5 subgroup. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02072681.

Background and Purpose: Clinical fluctuations in ischemic stroke symptoms are common, but fluctuations before hospital arrival have not been previously characterized. Methods: A standardized qualitative assessment of fluctuations before hospital arrival was obtained in an observational study that enrolled patients with mild ischemic stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score of 0–5) present on arrival to hospital within 4.5 hours of onset, in a subset of 100 hospitals participating in the Get With The Guidelines–Stroke quality improvement program. The number of fluctuations, direction, and the overall improvement or worsening was recorded based on reports from the patient, family, or paramedics. Baseline NIHSS on arrival and at 72 hours (or discharge if before) and final diagnosis and stroke subtype were collected. Outcomes at 90 days included the modified Rankin Scale, Barthel Index, Stroke Impact Scale 16, and European Quality of Life. Prehospital fluctuations were examined in relation to hospital NIHSS change (admission to 72 hours or discharge) and 90-day outcomes. Results: Among 1588 participants, prehospital fluctuations, consisting of improvement, worsening, or both were observed in 35.5%: 25.1% improved once, 5.3% worsened once, and 5.1% had more than 1 fluctuation. Those who improved were less likely and those who worsened were more likely to receive alteplase. Those who improved before hospital arrival had lower change in the hospital NIHSS than those who did not fluctuate. Better adjusted 90-day outcomes were noted in those with prehospital improvement compared to those without any fluctuations. Conclusions: Fluctuations in neurological symptoms and signs are common in the prehospital setting. Prehospital improvement was associated with better 90-day outcomes, controlling for admission NIHSS and alteplase treatment. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT 02072681.

A 54-year-old man was admitted to the intensive care unit with an aneurysmal subarachnoid hemorrhage and subsequently underwent mechanical ventilation and received neuromuscular blocking drugs to control refractory elevated intracranial pressure. During quantitative EEG monitoring, an automated alert was triggered by the train of four peripheral nerve stimulation artifacts. Real-time feedback was made possible due to remote monitoring. This case illustrates how computerized, automated artificial intelligence algorithms can be used beyond typical seizure detection in the intensive care unit for remote monitoring to benefit patient care., Highlights • ICU EEG provides an emerging opportunity for seizure detection (ictal) and interictal monitoring in the ICU setting. • Artifacts are plentiful in the ICU EEG setting. • Quantitative EEG (QEEG) with artificial neural-networks can be programmed to generate interesting artifacts that are not seizures, as the current example. • Such artifacts while not being epileptiform in nature, may still have clinical context such as moving the patient, suctioning intubated patients, being disconnected to go for CT scan, or in this case checking neuromuscular stimulation for neuromuscular blockade level.

Headache is a very common symptom in the neurointensive care unit (neuroICU). While headache in the neuroICU can be caused by worsening of a pre-existing primary headache disorder, most are secondary to another condition. Additionally, headache can be the presenting symptom of a number of conditions requiring prompt recognition and treatment including subarachnoid hemorrhage, ischemic and hemorrhagic stroke, central nervous system infection, pituitary apoplexy, and cerebral vasoconstriction. The neuroICU also has a unique postoperative population in which postcraniectomy and postcraniotomy headache, postintravascular intervention headache, hyperperfusion syndrome, ventriculitis, medication overuse or withdrawal headache, and hypercapnia may be encountered. Management varies dramatically depending on the etiology of the headache. Overreliance on opiate analgesics may produce significant adverse effects and lengthen ICU stays. However, nonnarcotic medications are increasingly being recognized as helpful in reducing the pain among various postsurgical and headache patients. Taken together, a multimodal approach targeting the underlying pathology and choosing appropriate systemic and local analgesic medications may be the best way to manage headache in critically ill patients.

The use of acute endovascular stroke intervention was called into question after the results of 2 negative stroke endovascular trials (Interventional Management of Stroke 3 [IMS-3] and Systemic Thrombolysis for Acute Ischemic Stroke per the Stroke Center registry [SYNTHESIS]).1,2 However, the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trial3 compared patients with acute stroke with proximal anterior circulation artery occlusions with usual stroke care, including intravenous tissue-type plasminogen activator (tPA). The study demonstrated a favorable shift in outcomes in the interventional group by modified Rankin Scale (mRS) by 90 days (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.21–2.30). Improvement in mRS was noted for all categories except for death. General anesthesia (GA) was used in 38% of the patients in the interventional group of MR CLEAN. In contrast, 9% of the patients in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE)4 trial received GA. The rate of functional independence (mRS, 0–2 by 90 days) was higher in the intervention group (53.0% versus 29.3%; P

Objective To assess the epidemiological aspects of central nervous system CNS fungal infections at tertiary care teaching hospitals Patients and methods We conducted a retrospective electronic medical record review of clinical radiographic laboratory and microbiological data from patients at Mayo Clinic Rochester MN and Jacksonville FL with a proven or probable diagnosis of a CNS fungal infection from January to December Results We identified proven probable CNS fungal infections had fungal meningitis had a tissue diagnosis and had CNS imaging indicative of infection with positive fungal cultures from other organs Most patients were male with a median age of years were immunosuppressed of whom received prednisone mg daily for weeks Cryptococcus spp was the most frequent infection identified and headache was the most common presenting symptom Survival was significantly worse for patients with CNS aspergillosis compared to those with CNS Cryptococcus spp hazard ratio P

Headache after aneurysmal subarachnoid hemorrhage (SAH) is very common and is often described as the “worst headache imaginable.” SAH-associated headache can persist for days to weeks and is traditionally treated with narcotics. However, narcotics can have significant adverse effects. We hypothesize that gabapentin (GBP), a non-narcotic neuropathic pain medication, would be safe and tolerable and would reduce narcotic requirements after SAH. We retrospectively reviewed the clinical, radiographic, and laboratory data of SAH patients at the neuroscience intensive care unit at Mayo Clinic in Jacksonville, Florida, from January 2011 through February 2013. Headache intensity was quantified by a visual analog scale score. Total opioid use per day was tabulated using an intravenous morphine equivalents scale. Cerebrospinal fluid was also reviewed when available. There were 53 SAH patients who were treated with GBP along with other analgesics for headache. Among these SAH patients, 34 (64 %) were women, with a mean age of 54 years (SD 12.3). Severe headache was observed in all SAH patients. GBP dosing was rapidly escalated within days of SAH up to a median of 1,200 mg/day, with a range of 300 mg three times a day to 900 mg three times a day. Approximately 6 % of patients treated with GBP had nausea (95 % CI 1–16 %), and only one patient (1.8 %) had to discontinue GBP. GBP appears to be relatively safe and tolerable in SAH patients with headache and may be a useful narcotic-sparing agent to prevent narcotics-associated complications, such as gastrointestinal immobility, ileus, and constipation.

Sickle cell disease may manifest with cerebrovascular and systemic complications. Sickle crisis that results in avascular necrosis of long bones with resultant cerebral fat embolism syndrome is rare and has a characteristic “starfield” pattern on MRI. This “starfield” MRI pattern should raise suspicion for sickle cell crisis in patients without a known history of the disease, which can lead to earlier sickle cell red blood cell exchange transfusion and treatment. We present a case of a male who presented emergently with acute seizure, coma with a characteristic MRI pattern, which lead to the diagnosis of avascular bone marrow necrosis and cerebral fat embolism syndrome from sickle cell crisis

Introduction: Therapeutic hypothermia (TH) for comatose survivors after cardiac arrest (CA) has been proven to improve neurological outcomes. However, the clinical examination, as well as other tests such as neuron specific enolase (NSE), somatosensory evoked potentials (SSEP), electroencephalograph