Monica Dhakar

A retrospective cross-sectional study of the prevalence of generalized convulsive status epilepticus in traumatic brain injury: United States 2002–2010

PURPOSE To determine the incidence, predictors, and outcomes of generalized convulsive status epilepticus (GCSE) in traumatic brain injury (TBI) patients. METHODS We conducted a retrospective cross-sectional study of adult patients with acute TBI using the 2002-2010 Nationwide Inpatient Sample (NIS) database of USA. We used multivariable logistic regression analyses to identify independent predictors of GCSE in patients with TBI and to determine the impact of GCSE on outcomes (in-hospital mortality, length of stay, total hospital charges, and discharge disposition). RESULTS Among 1,457,869 patients hospitalized with TBI, 2315 (0.16%) had GCSE. In-hospital mortality was significantly higher in patients with GCSE (32.5% vs. 9.6%; unadjusted OR 4.54, 95% CI 4.16-4.96; p<0.001; adjusted OR 3.41; 95% CI 3.09-3.76 p<0.001). Patients with GCSE had longer length of stay (17.3 ± 21.9 vs. 6.8 ± 11.1 days; p<0.001), higher total hospital charges (

A Cryptic Case: Isolated Cerebral Mucormycosis

147,415 ± 162,319 vs.

Continuous EEG Monitoring for Status Epilepticus

54,041 ± 90,524; p<0.001), and were less likely to be discharged home (19.8% vs. 52.7%; p<0.001). Using multivariable logistic regression analysis, age >35 years (OR 2.15; 95% CI 1.87-2.47), CNS infections (OR 4.86; 95% CI 3.70-6.38), anoxic brain injury (OR 9.54; 95% CI 8.10-11.22), and acute ischemic stroke (OR 4.09; 95% CI 3.41-4.87) were independent predictors of GCSE in TBI patients. Epilepsy was an independent negative predictor of GCSE (OR 0.74; 95% CI 0.55-0.99). CONCLUSION Despite its low incidence, GCSE in TBI patients was associated with worse outcomes with threefold higher in-hospital mortality, prolonged hospitalization, higher hospital charges, and worse discharge disposition. Surprisingly, epilepsy is a negative predictor of GCSE in this population.

F80. Seizures and hyperexcitable EEG patterns in spontaneous deep intraparenchymal hemorrhage

PRESENTATION A rare infection raging within the brain of a 50-year-old African-American man was impossible to diagnose until after his death. He presented to the emergency department after the acute onset of garbled speech, confusion, right-arm weakness, and right facial droop. His medical history was significant for poorly controlled diabetes mellitus and polysubstance abuse, including intravenous drug abuse. He had never had a stroke, had no sick contacts, and had not traveled recently.

Acute Onset Dystonia after Infarction of Premotor and Supplementary Motor Cortex

There has been a substantial increase in the use of continuous electroencephalography (C-EEG) in critically ill patients, most commonly for detection of nonconvulsive seizures. Studies have found that not only patients with primary brain insults but also those with systemic illness are at high risk of developing nonconvulsive status epilepticus (NCSE). The Neurocrit Care Society and The American Clinical Neurophysiology Society have published consensus statements or guidelines on the indications, duration, and technical aspects of EEG monitoring for status epilepticus (SE). Unified criteria for defining NCSE have also been proposed and published. Nevertheless, critically ill patients can have equivocal patterns, not clearly ictal (“ictal” is used to mean an electrographic seizure pattern in this chapter) or interictal, and have been considered to lie on an ictal-interictal continuum. Diagnostic treatment trials with IV benzodiazepines and non-sedating anti-seizure drugs (ASDs) can be helpful to determine if equivocal patterns are contributing to the patient’s impaired mental status or other neurologic deficits. The labor-intensive and time-consuming process of reviewing 24 h of EEG on many patients can be expedited by using tools such as quantitative EEG (Q-EEG) via commercial software packages. Thus far, there is some evidence to suggest that after strokes and head trauma, NCSE may worsen outcomes. Whether C-EEG monitoring and aggressive treatment of these seizures translates into improved patient outcomes is yet to be proven.

Acute Resective Surgery for the Treatment of Refractory Status Epilepticus

Introduction The incidence of electrographic seizures after non-traumatic intraparenchymal hemorrhage (IPH) ranges from 1.7% to 31%. It is unclear if the risk of seizures or hyperexcitable patterns (HEPs: any rhythmic delta activity except generalized, any periodic discharges, or any spike-wave pattern, using ACNS criteria) for deep IPH is similar to lobar, subarachnoid and subdural hemorrhages. We hypothesized that the incidence of seizures or hyperexcitable patterns (SZ or HEPs) in deep IPH is lower than reported, but thalamic involvement may confer higher risk due to its role in physiologic and pathologic rhythmic activity, such as sleep spindles and generalized spike wave discharges. Methods On retrospective review, 45 patients had deep IPH (defined as IPH not involving cortex/juxtacortical regions other than the insula (analyzed separately), with or without intraventricular hemorrhage IVH) and underwent continuous EEG (cEEG) between 1/2013 and 12/2016. Patients with involvement of cortex, subarachnoid or subdural areas were excluded. Age, sex, prior history of epilepsy, clinical seizure at ictus, anti-seizure drugs (ASDs), sedative infusions during EEG and surgical interventions such as ventriculostomy (EVD) or decompressive hemicraniectomy (DHC) were reviewed. The cEEG closest to admission was reviewed for seizures, HEPs, and generalized rhythmic delta activity (GRDA). The head CT in closest proximity to the index cEEG was reviewed for hematoma volume, thalamic involvement and insular involvement. Results Two of 45 patients had SZ, 7/45 had HEPs, 1/45 had both and a total of 8/45 had SZ or HEPs. Of the HEPs , LRDA was seen in 4/8, LPDs in 2/8, both LPDs and LRDA in 1/8. Of those with the lateralized HEPs, 4/7 were contralateral to IPH, 1/7 (14.2%) were bilateral and 2/7 were ipsilateral. Of the 5/7 with HEPs contralateral to the IPH, 2 had an EVD ipsilateral to the HEPs. Patients with SZ or HEPs had significantly higher hematoma volume compared to patients who did not have SZ or HEPs (32.7 ± 19.4 vs 15.4 ± 17.7, p  = 0.02). Patients who underwent surgery (DHC/EVD or both) had higher incidence of HEPs or SZ compared to those who did not (7/23, 30.4% vs 1/22, 4.5%, p  = 0.047). DHC was associated with significantly higher risk of SZ or HEPs (4/4, 100% vs 4/41, 9.8%, p Conclusion Risk of SZ or HEPs with deep IPH ± IVH was 17.7% and correlated with mean hematoma volume and DHC. The, risk in the absence of a surgical intervention was low (1/22, 4.5%, vs 7/23, 30.4% p  = 0.047). Thalamic involvement did not correlate with SZ or HEPs in this small cohort of patients with deep IPH.

Sacral Spine Myeloid Sarcoma

OBJECTIVE Poststroke dystonia is the second most common movement disorder after chorea and often has a delayed manifestation. Lesions of the contralateral lenticular nucleus, particularly the putamen, have been implicated in the pathogenesis of dystonia. We present an unusual case of rapid onset of focal dystonia of the left upper extremity, which developed after infarction of the right premotor cortex (PMC) and the supplementary motor area (SMA). METHOD A retrospective chart review of the patient was performed. RESULTS AND CONCLUSION We propose that disruption of the afferents from PMC and SMA in the setting of chronic striatal abnormality can result in acute dystonia due to disinhibition of the thalamocortical circuit.