Sherri A. Braksick

Associated Factors and Prognostic Implications of Stimulus-Induced Rhythmic, Periodic, or Ictal Discharges.

IMPORTANCE The implications of stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs) sometimes found on prolonged electroencephalographic (EEG) recordings are uncertain. OBJECTIVE To evaluate the incidence of SIRPIDs and their clinical implications in critically ill patients. DESIGN, SETTING, AND PARTICIPANTS A multicenter, international retrospective study was performed from October 1, 2012, through September 30, 2014, of consecutive adult patients hospitalized in intensive care units with alteration of consciousness who underwent EEG recordings at 3 separate centers. Demographic data, including admission diagnosis, age, sex, history of epilepsy, and EEG findings, were noted. Characteristics of SIRPIDs were documented. Data were evaluated for predictors of SIRPIDs and in-hospital mortality. Data analysis was performed from January 16, 2015, to June 15, 2015. MAIN OUTCOMES AND MEASURES Incidence of SIRPIDs, association of SIRPIDs with mortality and other EEG characteristics, and EEG and clinical predictors of mortality. RESULTS A total of 416 patients were studied. The median age of patients was 60 years (interquartile range, 46-71 years), and 252 (60.6%) were male. A total of 104 patients (25.0%) did not survive to hospital discharge. SIRPIDs were identified in 43 patients (10.3%). The proportion of patients with SIRPIDs was not significantly different across the 3 sites (P = .34). Anoxic brain injury (odds ratio [OR], 3.80; 95% CI, 1.73-8.33; P < .001), the use of antiepileptic medications (OR, 3.24; 95% CI, 1.31-8.00; P = .01), electrographic seizures (OR, 2.85; 95% CI, 1.13-7.19; P = .03), generalized periodic discharges with triphasic morphologic features (OR, 3.66; 95% CI, 1.67-8.02; P = .001), and sporadic sharp waves and periodic discharges (OR, 2.59; 95% CI, 1.13-5.92; P = .02) were independently associated with the presence of SIRPIDs. Older age (OR, 1.02; 95% CI, 1.01-1.04; P = .005), anoxic brain injury (OR, 3.49; 95% CI, 1.96-6.21; P ≤ .001), and absence of EEG reactivity (OR, 8.14; 95% CI, 4.20-15.79; P < .001) but not SIRPIDs (OR, 1.73; 95% CI, 0.79-3.78; P = .17) were independently associated with in-hospital mortality. CONCLUSIONS AND RELEVANCE In critically ill patients undergoing EEG recordings, SIRPIDs occurred in 43 (10.3%) and were associated with other electrographic abnormalities previously reported to indicate poor prognosis. However, SIRPIDs were not independently associated with in-hospital mortality.

Amyloid–β-related angiitis presenting as a uveomeningeal syndrome

A 59-year-old man had a 2-month history of nonfluctuating encephalopathy. He initially presented acutely with fevers, headaches, and word-finding difficulties. The sedimentation rate was elevated with a bland CSF and normal MRI head. Body CT showed diffuse pulmonary interstitial thickening with patchy opacification. Following treatment for pneumonia, there was resolution of fevers. No infectious etiology was identified. Within days of discharge, he developed bilateral uveitis, which was successfully treated with corticosteroid eyedrops and oral acyclovir. One month later, he developed confusion and unsteadiness. Repeat MRI was reportedly normal; body CT showed resolution of lung changes but diffuse lymphadenopathy persisted. A lymph node biopsy, reviewed at our institution, showed nonspecific reactive changes and fibrosis. Due to progressive encephalopathy and worsening headaches 2 months after symptom onset, the patient presented to our institution. On examination, he scored 30/38 on the Kokmen short test of mental status,1 losing points for attention and immediate and delayed recall. Funduscopy revealed bilateral disc edema. He had mild appendicular ataxia and impaired tandem walk. The remainder of the examination was normal.

Teaching NeuroImages: MRI in advanced neuromyelitis optica

A 51-year-old woman was treated with multiple medications for relapsing-remitting multiple sclerosis (MS) over 20 years, including interferons and glatiramer, but continued to have recurrent attacks of optic neuritis and transverse myelitis, leading to bilateral blindness and triplegia. Even with MS-type lesions on MRI, neuromyelitis optica (NMO) was ultimately suspected and confirmed by detection of aquaporin-4 autoantibodies. MRI showed nonenhancing T2 linear hyperintensity around the ventricular system in areas known to highly express aquaporin-4 (figure).1 Profound spinal cord atrophy was evident, consistent with severe, chronic NMO. This case illustrates the lack of effectiveness and potential detriment when MS-directed immunomodulatory medications are aimed at NMO.2

Influence of Antithrombotics on the Etiology of Intracerebral Hemorrhage

BACKGROUND To determine the influence of antithrombotic use on the etiology of primary intracerebral hemorrhage (ICH). METHODS We conducted a retrospective review of consecutive patients admitted with primary ICH from 2009 to 2012. Data recorded included age, history of hypertension, and use of antithrombotic medications. Imaging was reviewed to determine hemorrhage location and the presence and the location of any microhemorrhages. Etiologies were classified using a predetermined algorithm, which was based on existing literature. RESULTS In total, 292 patients were included. Median age was 74 years (range, 18-101), and 52% were male (n = 151). Hemorrhage etiology was hypertension in 50.6% (n = 148), indeterminate in 29.5% (n = 86), and cerebral amyloid angiopathy (CAA) in 19.9% (n = 58). Most patients were on antithrombotics (61.3%, n = 179). Nearly half of the patients (49%) were 75 years of age or older, and the most common etiology in this group was hypertension (n = 77, 53%). There was a nonsignificant trend toward older age and CAA-ICH (median age, 77 years; interquartile range [IQR], 70-82 years) compared with other causes (median age, 74 years; IQR, 61-82 years; P = .07). There was no difference between CAA-ICH and other-cause ICH with respect to proportion of patients on antithrombotics in general (67% versus 60%; P = .367) or anticoagulants in particular (24% versus 25%; P = 1.000). CONCLUSIONS The most common ICH etiology in this study was hypertension, regardless of age. Our findings do not suggest that the higher occurrence of ICH in older patients or in patients with CAA-associated ICH is because of a higher frequency of anticoagulant use.

Moisture and mydriasis

A 31-year-old female was admitted to the hospital for a pericardectomy secondary to constrictive pericarditis. On the fourth postoperative day, neurology was urgently consulted because of an alarming acute wide pupil. She had no headache, ocular pain, diplopia, ptosis or other neurologic symptoms. Neurologic examination showed left mydriasis (9 mm) while the right pupil measured 3 mm (figure 1). Pupillary light reflex was normal bilaterally. The remainder of the neurologic examination was unremarkable. There was decreased intraocular pressure in the left eye (9 mm Hg vs 12 mm Hg) as assessed by the consulted ophthalmologist who found no other abnormalities. Throughout the hospitalisation, …

Bilateral Middle Cerebral Artery Occlusion In Rapid Succession During Thrombolysis

A 76-year-old female developed acute left hemiplegia, dysarthria, right gaze preference, and cerebral ptosis. Computed tomography (CT) scan demonstrated an Alberta Stroke Program Early CT Score (ASPECTS) of 10 and a hyperdense right middle cerebral artery (MCA) (Figure 1A and B). Shortly after the bolus of Tissue Plasminogen Activator (tPA) with the infusion running, she abruptly became comatose. A repeat CT scan showed the resolution of her gaze preference and a new hyperdense left MCA sign (Figure 1C and D). Cerebral angiogram confirmed complete occlusion of the proximal MCA bilaterally (Figure 2). Despite attempts at clot retrieval, flow was partially restored. Transesophageal echocardiogram demonstrated left atrial enlargement without thrombus. The patient remained comatose and, given her prior wishes, was transitioned to palliative care.

Application of the FOUR Score in Intracerebral Hemorrhage Risk Analysis

BACKGROUND The Full Outline of Unresponsiveness (FOUR) Score is a validated scale describing the essentials of a coma examination, including motor response, eye opening and eye movements, brainstem reflexes, and respiratory pattern. We incorporated the FOUR Score into the existing ICH Score and evaluated its accuracy of risk assessment in spontaneous intracerebral hemorrhage (ICH). MATERIALS AND METHODS Consecutive patients admitted to our institution from 2009 to 2012 with spontaneous ICH were reviewed. The ICH Score was calculated using patient age, hemorrhage location, hemorrhage volume, evidence of intraventricular extension, and Glasgow Coma Scale (GCS). The FOUR Score was then incorporated into the ICH Score as a substitute for the GCS (ICH ScoreFS). The ability of the 2 scores to predict mortality at 1 month was then compared. RESULTS In total, 274 patients met the inclusion criteria. The median age was 73 years (interquartile range 60-82) and 138 (50.4%) were male. Overall mortality at 1 month was 28.8% (n = 79). The area under the receiver operating characteristic curve was .91 for the ICH Score and .89 for the ICH ScoreFS. For ICH Scores of 1, 2, 3, 4, and 5, 1-month mortality was 4.2%, 29.9%, 62.5%, 95.0%, and 100%. In the ICH ScoreFS model, mortality was 10.7%, 26.5%, 64.5%, 88.9%, and 100% for scores of 1, 2, 3, 4, and 5, respectively. CONCLUSIONS The ICH Score and the ICH ScoreFS predict 1-month mortality with comparable accuracy. As the FOUR Score provides additional clinical information regarding patient status, it may be a reasonable substitute for the GCS into the ICH Score.

Post-ischemic Myoclonic Status Following Cardiac Arrest in Young Drug Users

BackgroundMyoclonic status may be observed following cardiac arrest and has previously been identified as a poor prognostic indicator in regard to return of neurologic function. We describe a unique situation in post-cardiac arrest patients with myoclonic status and hypothesize possible predictors of a good neurologic outcome.MethodsCase series.ResultsWe illustrate two cases of cardiac arrest due to a respiratory cause in young patients with evidence of illicit drug use at the time of hospital admission that suffered post-ischemic myoclonic status. These patients subsequently recovered with good neurologic outcomes.ConclusionsOn rare occasions, myoclonic status does not imply a poor functional outcome following cardiac arrest. Other clinical and demographic characteristics including young age, presence of illicit substances, and primary respiratory causes of arrest may contribute to a severe clinical presentation, with a subsequent good neurologic outcome in a small subset of patients.

An NIHSS of 0 and a Very Disabling Stroke.

Acute ischemic strokes can have devastating functional consequences; and available treatments are time-limited, potentially exposing the patient to undue risk if thrombolytic therapy or thrombectomy is delayed or administered inappropriately. Therefore, it is imperative that providers be able to readily identify signs of ischemia to allow for prompt and efficient treatment. A standardized assessment, the National Institutes of Health Stroke Scale (NIHSS), is widely implemented and considered standard practice for evaluation of patients with suspected stroke [1–3]. Moreover, in the USA, failure to consistently record a standardized stroke scale may affect stroke center accreditation status. While the NIHSS allows for an efficient examination, it is not a substitute for a formal neurologic assessment; and clinicians may encounter a disabling stroke even in the presence of an apparently normal NIHSS examination. We present a case of a patient with a normal NIHSS but with a disabling deficit in the midbrain. Case Presentation

Ventriculostomy and Risk of Upward Herniation in Patients with Obstructive Hydrocephalus from Posterior Fossa Mass Lesions

BackgroundPatients with posterior fossa lesions causing obstructive hydrocephalus present a unique clinical challenge, as relief of hydrocephalus can improve symptoms, but the perceived risk of upward herniation must also be weighed against the risk of worsening or continued hydrocephalus and its consequences. The aim of our study was to evaluate for clinically relevant upward herniation following external ventricular drainage (EVD) in patients with obstructive hydrocephalus due to posterior fossa lesions.MethodsWe performed a retrospective review of patients undergoing urgent/emergent EVD placement at our institution between 2007 and 2014, evaluating the radiographic and clinical changes following treatment of obstructive hydrocephalus.ResultsEven prior to EVD placement, radiographic upward herniation was present in 22 of 25 (88%) patients. The average Glasgow Coma Scale of patients before and after EVD placement was 10 and 11, respectively. Radiographic worsening of upward herniation occurred in two patients, and upward herniation in general persisted in 21 patients. Clinical worsening occurred in two patients (8%), though in all others the clinical examination remained stable (44%) or improved (48%) following EVD placement. Of the patients who had a worsening clinical exam, other variables likely also contributed to their decline, and cerebrospinal fluid diversion was likely not the main factor that prompted the clinical change.ConclusionsRadiographic presence of upward herniation was often present prior to EVD placement. Clinically relevant upward herniation was rare, with only two patients worsening after the procedure, in the presence of other clinical confounders that likely contributed as well.