Weibi Chen

Valproate versus diazepam for generalized convulsive status epilepticus: a pilot study

Background and purpose:  Evidence‐based data to guide the management of status epilepticus (SE) after failure of primary treatment are still scarce and the alternate needs to be found when phenytoin (PHT) is not available or contraindicated. Comparison of intravenous (IV) valproate (VPA) and diazepam (DZP) infusion has not been conducted in adults with SE. This prospective randomized controlled trial is thus designed to evaluate the relative efficacy and safety of IV VPA and continuous DZP infusion as second‐line anticonvulsants.

Improved Neurological Outcome With Mild Hypothermia in Surviving Patients With Massive Cerebral Hemispheric Infarction

Background and Purpose— We conducted this randomized controlled trial to investigate the effects of therapeutic hypothermia on mortality and neurological outcome in patients with massive cerebral hemispheric infarction. Methods— Patients within 48 hours of symptom onset were randomized to either a hypothermia group or a control group. Patients in the hypothermia group were given standard medical treatment plus endovascular hypothermia with a target temperature of 33 or 34°C. Hypothermia was maintained for a minimum of 24 hours. Patients in the control group were given standard medical treatment only with a target temperature of normothermia. The primary end points were mortality and the modified Rankin Scale score at 6 months. Results— There were 16 patients in the hypothermia group and 17 patients in the control group. At 6 months, 8 patients had died in the hypothermia group versus 7 patients in the control group (P=0.732). The main cause of death was fatal herniation caused by a pronounced rise in intracranial pressure. Seven patients (43.8%) had a modified Rankin Scale of 1 to 3 in the hypothermia group versus 4 patients (23.5%) in the control group (P=0.282). Additionally, of the survivors, patients in the hypothermia group achieved better neurological outcomes compared with those in the control group (7/8, 87.5% versus 4/10, 40.0%; P=0.066; odds ratio=10.5; 95% confidence interval, 0.9–121.4). Conclusions— Mild hypothermia seems to not reduce mortality in patients with massive cerebral hemispheric infarction but may improve the neurological outcome in survivors. An adequately powered multicenter randomized controlled trial seems warranted. Clinical Trial Registration— URL: http://www.chictr.org.cn. Unique identifier: ChiCTR-TCS-12002680.

Poor outcome prediction by burst suppression ratio in adults with post-anoxic coma without hypothermia

Abstract Purpose: Burst suppression ratio (BSR) is a quantitative electroencephalography (qEEG) parameter. The purpose of our study was to compare the accuracy of BSR when compared to other EEG parameters in predicting poor outcomes in adults who sustained post-anoxic coma while not being subjected to therapeutic hypothermia. Methods: EEG was registered and recorded at least once within 7 days of post-anoxic coma onset. Electrodes were placed according to the international 10–20 system, using a 16-channel layout. Each EEG expert scored raw EEG using a grading scale adapted from Young and scored amplitude-integrated electroencephalography tracings, in addition to obtaining qEEG parameters defined as BSR with a defined threshold. Glasgow outcome scales of 1 and 2 at 3 months, determined by two blinded neurologists, were defined as poor outcome. Results: Sixty patients with Glasgow coma scale score of 8 or less after anoxic accident were included. The sensitivity (97·1%), specificity (73·3%), positive predictive value (82·5%), and negative prediction value (95·0%) of BSR in predicting poor outcome were higher than other EEG variables. BSR1 and BSR2 were reliable in predicting death (area under the curve > 0·8, P < 0·05), with the respective cutoff points being 39·8% and 61·6%. BSR1 was reliable in predicting poor outcome (area under the curve  =  0·820, P < 0·05) with a cutoff point of 23·9%. BSR1 was also an independent predictor of increased risk of death (odds ratio  =  1·042, 95% confidence intervals: 1·012–1·073, P  =  0·006). Discussion: BSR may be a better predictor in prognosticating poor outcomes in patients with post-anoxic coma who do not undergo therapeutic hypothermia when compared to other qEEG parameters.

Early Hypothermia for Refractory Status Epilepticus.

IntroductIon Currently, the recommended therapy to control refractory status epilepticus (RSE) is intravenous (IV) anesthetics, such as midazolam, propofol, barbiturates, and so on. However, 15%–26% of RSE cases still cannot be terminated. Three case series studies have demonstrated that the combination of IV anesthetics and moderate (30–31°C) or mild (31–35°C) hypothermia successfully terminated the seizures in RSE patients.[1,2] But the high rebound rate after rewarming, high mortality rate during hospitalization and severe neurological deficits were still unsatisfactory.[1,2] We hypothesized that starting hypothermia earlier, an hour after IV anesthetic, rather than a few days later, may get the best effect on the termination of RSE and has a better prognosis. The purpose of this research was to confirm the effect of the combination of early hypothermia and IV anesthetic on suppressing seizures and improving prognosis.

Electroencephalography reactivity for prognostication of post-anoxic coma after cardiopulmonary resuscitation: A comparison of quantitative analysis and visual analysis.

Electroencephalogram reactivity (EEG-R) is a positive predictive factor for assessing outcomes in comatose patients. Most studies assess the prognostic value of EEG-R utilizing visual analysis; however, this method is prone to subjectivity. We sought to categorize EEG-R with a quantitative approach. We retrospectively studied consecutive comatose patients who had an EEG-R recording performed 1-3 days after cardiopulmonary resuscitation (CPR) or during normothermia after therapeutic hypothermia. EEG-R was assessed via visual analysis and quantitative analysis separately. Clinical outcomes were followed-up at 3-month and dichotomized as recovery of awareness or no recovery of awareness. A total of 96 patients met the inclusion criteria, and 38 (40%) patients recovered awareness at 3-month followed-up. Of 27 patients with EEG-R measured with visual analysis, 22 patients recovered awareness; and of the 69 patients who did not demonstrated EEG-R, 16 patients recovered awareness. The sensitivity and specificity of visually measured EEG-R were 58% and 91%, respectively. The area under the receiver operating characteristic curve for the quantitative analysis was 0.92 (95% confidence interval, 0.87-0.97), with the best cut-off value of 0.10. EEG-R through quantitative analysis might be a good method in predicting the recovery of awareness in patients with post-anoxic coma after CPR.

Protocol-directed weaning from mechanical ventilation in neurological patients: a randomised controlled trial and subgroup analyses based on consciousness

Abstract Objectives: To assess whether a weaning protocol reduces the mechanical ventilation (MV) duration compared to physicians judgement-based weaning in neurological patients and to determine whether patient consciousness influences this reduction. Methods: A randomised controlled trial was conducted in a neurological intensive care unit (NCU) of a tertiary hospital; 144 patients requiring MV for more than 24 hours were randomly allocated to protocol-directed (intervention) (n = 71) or physician-directed (control) group (n = 73). Results: The intervention group displayed a significantly shorter median weaning time than the control group (2.00 vs 5.07 days, P < 0.05). The median MV duration tended to be shorter in the intervention group (10.8 vs 14.2 days, P = 0.106). The median length of NCU stay was 19.0 and 26.1 days in the intervention and control groups, respectively (P = 0.063). The median NCU cost was 9.26 × 104 and 12.24 × 104 ¥ in the intervention and control groups, respectively (P = 0.059). The unsuccessful weaning, ventilator-associated pneumonia (VAP) and mortality rates were similar between the groups. Among conscious patients, the median weaning time (2.00 vs 7.00 days, P < 0.05) and the median MV duration (8.8 vs 18.0 days, P = 0.017) were significantly reduced in the intervention group. Among unconscious patients, the intervention group displayed a reduced median weaning time (1.00 vs 3.10 days, P < 0.05), but not median MV duration (11.6 vs 11.1 days, P = 0.702), compared to the control group. Conclusion: Protocol-directed weaning reduces weaning time, MV duration, length of NCU stay and NCU cost in neurological patients, and these effects are more significant in conscious patients than in unconscious patients.

Status epilepticus associated with acute encephalitis: long-term follow-up of functional and cognitive outcomes in 72 patients

Continued care in patients with encephalitis and prolonged status epilepticus (SE) is controversial. Limited data are available on the functional and cognitive outcomes.

Module modified acute physiology and chronic health evaluation II: predicting the mortality of neuro-critical disease

Abstract Objectives: This study aimed to conduct and assess a module modified acute physiology and chronic health evaluation (MM-APACHE) II model, based on disease categories modified-acute physiology and chronic health evaluation (DCM-APACHE) II model, in predicting mortality more accurately in neuro-intensive care units (N-ICUs). Methods: In total, 1686 patients entered into this prospective study. Acute physiology and chronic health evaluation (APACHE) II scores of all patients on admission and worst 24-, 48-, 72-hour scores were obtained. Neurological diagnosis on admission was classified into five categories: cerebral infarction, intracranial hemorrhage, neurological infection, spinal neuromuscular (SNM) disease, and other neurological diseases. The APACHE II scores of cerebral infarction, intracranial hemorrhage, and neurological infection patients were used for building the MM-APACHE II model. Results: There were 1386 cases for cerebral infarction disease, intracranial hemorrhage disease, and neurological infection disease. The logistic linear regression showed that 72-hour APACHE II score (Wals  =  173·04, P < 0·001) and disease classification (Wals  =  12·51, P  =  0·02) were of importance in forecasting hospital mortality. Module modified acute physiology and chronic health evaluation II model, built on the variables of the 72-hour APACHE II score and disease category, had good discrimination (area under the receiver operating characteristic curve (AU-ROC  =  0·830)) and calibration (χ2  =  12·518, P  =  0·20), and was better than the Knaus APACHE II model (AU-ROC  =  0·778). Discussion: The APACHE II severity of disease classification system cannot provide accurate prognosis for all kinds of the diseases. A MM-APACHE II model can accurately predict hospital mortality for cerebral infarction, intracranial hemorrhage, and neurologic infection patients in N-ICU.

RSE prediction by EEG patterns in adult GCSE patients

BACKGROUND Electroencephalogram (EEG) can predict mortality in status epilepticus (SE) patients. However, we consider that the prediction for refractory status epilepticus (RSE) after SE initial treatment is more significant than long-term prognosis of SE. The objective of this study is to detect some predictive EEG patterns for RSE. METHODS Pooled data derived from two randomized controlled trials (RCTs) were prospectively analyzed in adult generalized convulsive status epilepticus (GCSE) patients. RESULTS Etiology, GCSE duration and EEG patterns are three factors which were statistically different between non-RSE and RSE groups. However, when we introduced these factors into multivariable logistic regression model, only EEG pattern was an independent risk factor for RSE prediction. Comparing with rhythmic fast activities background (RFAB) pattern, there were positive correlations between interictal epileptiform discharges (IEDs), periodic epileptic discharges/subtle status epilepticus (PEDs/subtle SE) patterns and RSE incidence respectively. CONCLUSIONS There was an increased risk of RSE incidence accompanied with IEDs and PEDs/subtle SE patterns appearance. Clinicians should adjust anti-epileptic strategies with the aid of these EEG patterns in order to reduce RSE incidence.

Cerebral Venous Sinus Thrombosis as the First Manifestation of JAK2V617F-positive Essential Thrombocythemia

To the Editor: Essential thrombocythemia (ET) complicated by cerebral venous sinus thrombosis (CVST) is exceptionally rare. Hitherto, few studies have mentioned the role of Janus kinase 2V617F (JAK2V617F) mutation in ET patients who developed CVST; thus, the strategy and long‐term outcomes are yet rarely reported. The present study documented four cases, wherein CVST was the first manifestation of JAK2V617F‐positive ET.