Status Epilepticus in Older Adults: Diagnostic and Treatment Considerations.

Status epilepticus (SE) is one of the leading life-threatening neurological emergencies in the elderly population, with significant morbidity and mortality. SE presents unique diagnostic and therapeutic challenges in the older population given overlap with other causes of encephalopathy, complicating diagnosis, and the common occurrence of multiple comorbid diseases complicates treatment. First-line therapy involves the use of rescue benzodiazepine in the form of intravenous lorazepam or diazepam, intramuscular or intranasal midazolam and rectal diazepam. Second-line therapies include parenteral levetiracetam, fosphenytoin, valproate and lacosamide, and underlying comorbidities guide the choice of appropriate medication, while third-line therapies may be influenced by the patient's code status as well as the cause and type of SE. The standard of care for convulsive SE is treatment with an intravenous anesthetic, including midazolam, propofol, ketamine and pentobarbital. There is currently limited evidence guiding appropriate therapy in patients failing third-line therapies. Adjunctive strategies may include immunomodulatory treatments, non-pharmacological strategies such as ketogenic diet, neuromodulation therapies and surgery in select cases. Surrogate decision makers should be updated early and often in refractory episodes of SE and informed of the high morbidity and mortality associated with the disease as well as the high probability of subsequent epilepsy among survivors.

Thalamic venous infarction from trauma mimicking a glioma.

Traumatic brain injuries (TBI) are commonly associated with motor vehicle accidents. Neuroimaging plays a crucial role in the initial management of TBIs. We present a case of a TBI related to a motor vehicle accident in an 18-year-old woman. Initial brain imaging revealed significant traumatic injuries and an enhancing mass, without restricted diffusion, in the thalamus favored to be a thalamic glioma. Subsequent imaging revealed resolution of enhancement of the thalamic lesion and reduction in size. On review of the original imaging, it was determined that the thalamic lesion was related to a tear and partial thrombosis of a large thalamic vein resulting in infarction and hemorrhage.

Communication Challenges: A Spotlight on New-Onset Refractory Status Epilepticus.

New-onset refractory status epilepticus (NORSE) is a rare, potentially devastating condition that occurs abruptly in previously healthy patients of any age but most commonly in children and young adults. It has an unpredictable clinical course requiring immediate, often prolonged, critical care support with multiple specialists involved and frequently results in severe life-altering sequelae or death. Communication in NORSE is challenging because its etiology in a given patient is initially unknown (and often remains so), the clinical course and outcome are unpredictable, and many health care team members are involved in the care of a patient. We address the communication challenges seen in NORSE through proactive communication on 3 levels: (1) in the shared decision-making process with the family, (2) within an individual hospital, and (3) across institutions. Intentional organizational change and enhanced information dissemination may help break down barriers to effective communication. Key initiatives for enhancing information dissemination in NORSE are (1) the identification of a most responsible physician to integrate information from subspecialties, to communicate frequently and candidly with the family, and to provide continuity of care over a prolonged period of time and (2) the early involvement of palliative care services alongside ongoing therapies with curative intent to support families and the medical team in decision making and communication.

At the Intersection of Patient Experience Data, Outcomes Research, and Practice: Analysis of HCAHPS Scores in Neurology Patients.

OBJECTIVE: To assess variation in patient-reported experience in inpatient neurology patients. PATIENTS AND METHODS: We retrospectively identified 1045 patients 18 years and older admitted to a neurology service and discharged from January 1, 2013, through September 30, 2016, who completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Multivariable logistic regression evaluated the associations of patient factors with HCAHPS measures. Key driver analysis identified associations between HCAHPS measures and the Global score (combination of 0-10 hospital rating and likelihood to recommend). Multivariable logistic regression compared HCAHPS scores between neurology patients and those admitted to a neurosurgery (n=2190) or internal medicine (n=3401) service during the same period. RESULTS: Among patients admitted to a neurology service, overall (summary) scores did not vary significantly by diagnosis after adjustment for age, education, and overall health, but patients with neurologic diagnoses other than stroke, epilepsy, and neurodegenerative disease were more likely to report lower Pain Management scores compared with patients with cancer. Key driver analysis showed Care Transition scores as drivers of the Global score. After adjustment, general internal medicine service patients were more likely to report low Summary scores and neurosurgery service patients were significantly less likely to report low Summary scores compared with neurology service patients. CONCLUSION: Efforts to improve how neurology patients experience their care should be aimed at targeting patients' perceptions of pain management, and improving care transitions is an important first-priority target for improvement. This analysis may help other institutions improve hospital rating, value-based payments, and patient-centered outcomes.

West Nile virus induces a post-infectious pro-inflammatory state that explains transformation of stable ocular myasthenia gravis to myasthenic crises.

West Nile virus (WNV) infection has been reported to promote myasthenia gravis (MG) and various other diseases that have a presumed autoimmune pathogenesis. Molecular mimicry between WNV proteins and host proteins has been postulated as the major mechanism for WNV-triggered breaking of immunological self-tolerance. We present a patient with stable ocular MG and positive anti-acetylcholine receptor antibodies who progressed to myasthenic crisis after WNV neuroinvasive disease. In this case of stable autoimmune disease with proven auto-antibodies, transformation to generalized disease cannot be attributed to molecular mimicry, which requires that an immune response first be generated against an infectious agent. Rather, the evidence supports the concept of a post-infectious pro-inflammatory state that may contribute to the amplification and promotion of autoimmune disease in some WNV survivors.

Comparison of Ocular Ultrasonography and Magnetic Resonance Imaging for Detection of Increased Intracranial Pressure.

BACKGROUND/AIMS: To evaluate and compare the performance of ocular ultrasonography (US) and magnetic resonance imaging (MRI) for detecting increased intracranial pressure (ICP) in patients with idiopathic intracranial hypertension (IIH). METHODS: Twenty-two patients with papilledema from IIH and 22 with pseudopapilledema were prospectively recruited based on funduscopic and clinical findings. Measurements of optic nerve sheath diameters (ONSDs) 3 mm behind the inner sclera were performed on B-scan US and axial T2-weighted MRI examinations. Pituitary-to-sella height ratio (pit/sella) was also calculated from sagittal T1-weighted MRI images. Lumbar puncture was performed in all patients with IIH and in five patients with pseudopapilledema. RESULTS: Average US and MRI ONSD were 4.4 (SD ± 0.7) and 5.2 ± 1.4 mm for the pseudopapilledema group and 5.2 ± 0.6 and 7.2 ± 1.6 mm for the papilledema group (p < 0.001). Average MRI pit/sella ratio was 0.7 ± 0.3 for the pseudopapilledema group and 0.3 ± 0.2 for the papilledema group (p < 0.001). Based on receiver-operator curve analysis, the optimal thresholds for detecting papilledema are US ONSD > 4.8 mm, MRI ONSD > 6.0 mm, and MRI pit/sella < 0.5. Combining a dilated US ONSD or MRI ONSD with a below-threshold MRI pit/sella ratio yielded a sensitivity of 73% and specificity of 96% for detecting IIH. Adding the US ONSD to the MRI ONSD and pit/sella ratio only increased the sensitivity by 5% and did not change specificity. CONCLUSION: US and MRI provide measurements of ONSD that are well-correlated and sensitive markers for increased ICP. The combination of the ONSD and the pit/sella ratio can increase specificity for the diagnosis of IIH.

Neurologic Complications of Commonly Used Drugs in the Hospital Setting.

This chapter reviews the neurologic complications of medications administered in the hospital setting, by class, introducing both common and less common side effects. Detail is devoted to the interaction between pain, analgesia, sedation, and their residual consequences. Antimicrobials are given in nearly every hospital setting, and we review their capacity to produce neurologic sequelae with special devotion to cefepime and the antiviral treatment of human immunodeficiency virus. The management of hemorrhagic stroke has become more complex with the introduction of novel oral anticoagulants, and we provide an update on what is known about reversal of the new oral anticoagulants. Both central and peripheral nervous system complications of immunosuppressants and chemotherapies are reviewed. Because diagnosis is generally based on clinical acumen, alone, neurotoxic syndromes resulting from psychotropic medications may be easily overlooked until severe dysautonomia develops. We include a practical approach to the diagnosis of serotonin syndrome and neuroleptic malignant syndrome.

Autoimmune Encephalitis in the ICU: Analysis of Phenotypes, Serologic Findings, and Outcomes.

BACKGROUND: To report the clinical and laboratory characteristics, clinical courses, and outcomes of Mayo Clinic, Rochester, MN, ICU-managed autoimmune encephalitis patients (January 1st 2003-December 31st 2012). METHODS: Based on medical record review, twenty-five patients were assigned to Group 1 (had ≥1 of classic autoimmune encephalitis-specific IgGs, n = 13) or Group 2 (had ≥3 other characteristics supporting autoimmunity, n = 12). RESULTS: Median admission age was 47 years (range 22-88); 17 were women. Initial symptoms included ≥1 of subacute confusion or cognitive decline, 13; seizures, 12; craniocervical pain, 5; and personality change, 4. Thirteen Group 1 patients were seropositive for ≥1 of VGKC-complex-IgG (6; including Lgi1-IgG in 2), NMDA-R-IgG (4), AMPA-R-IgG (1), ANNA-1 (1), Ma1/Ma2 antibody (1), and PCA-1 (1). Twelve Group 2 patients had ≥3 other findings supportive of an autoimmune diagnosis (median 4; range 3-5): ≥1 other antibody type detected, 9; an inflammatory CSF, 8; ≥1 coexisting autoimmune disease, 7; an immunotherapy response, 7; limbic encephalitic MRI changes, 5; a paraneoplastic cause, 4; and diagnostic neuropathological findings, 2. Among 11 patients ICU-managed for ≥4 days, neurological improvements were attributable to corticosteroids (5/7 treated), plasmapheresis (3/7), or rituximab (1/3). At last follow-up, 10 patients had died. Of the remaining 15 patients, 6 (24%) had mild or no disability, 3 (12%) had moderate cognitive problems, and 6 (24%) had dementia (1 was bed bound). Median modified Rankin score at last follow-up was 3 (range 0-6). CONCLUSIONS: Good outcomes may occur in ICU-managed autoimmune encephalitis patients. Clinical and testing characteristics are diverse. Comprehensive diagnostics should be pursued to facilitate timely treatment.

Neurologic complications of liver transplantation.

A new spectrum of neurologic complications has appeared with treatment of the organ transplant recipient. There are specific problems in liver recipients. Most pertinent is the management of acute fulminant hepatic failure and emerging brain edema that can only be definitively treated with acute liver transplantation. In some patients neurologic complications appear as a result of immunosuppressive drugs or due to infectious complications in immunocompromised patients. Neurologists seeing patients in a transplant unit should be prepared to see confused or obtunded critically ill patients with multiple medical problems, procedures, and polypharmacy. This chapter discusses the challenges of the transplant team and the consulting neurologist.

Indicators of central fever in the neurologic intensive care unit.

IMPORTANCE: Fever is common in critically ill neurologic patients. Knowledge of the indicators of central fever may allow greater antibiotic stewardship in this era of rapidly developing super-resistant microorganisms. OBJECTIVE: To develop a model to differentiate central from infectious fever in critically ill neurologic patients with fever of an undetermined cause. DESIGN, SETTING, AND PARTICIPANTS: Retrospective data collection from January 1, 2006, through December 31, 2010, at a 20-bed neurologic intensive care unit of a large teaching hospital. Consecutive patients 18 years and older admitted for 48 hours or longer with a core body temperature higher than 38.3 °C on at least 1 measurement for 2 consecutive days. Patients with alternative identified causes of noninfectious fever were excluded. In total, 526 patients were included in the final analysis. MAIN OUTCOMES AND MEASURES: Percentage incidence and odds ratios of variables associated with central fever. Fever was classified as infectious if there was culture growth of a pathogenic species or documented clinical diagnosis of infection treated with antibiotics. Remaining patients were considered to have central fever. Continuous fever lasting longer than 6 hours for 2 or more consecutive days was considered persistent. RESULTS Fever was central in 246 patients (46.8%). Patients with infectious fever were older (mean, 57.4 vs 53.5 years; P = .01) and had a longer length of stay in the neurologic intensive care unit (mean, 12.1 vs 8.8 days; P < .001). Central fever was more likely to occur within 72 hours of admission to the neurologic intensive care unit (76.4% vs 60.7%; P < .001) and tended to be persistent (26.4% vs 18.6%; P = .04). Blood transfusion (odds ratio [OR], 3.06; 95% CI, 1.63-5.76); absence of infiltrate on chest x-ray (3.02; 1.81-5.05); diagnosis of subarachnoid hemorrhage, intraventricular hemorrhage, or tumor (6.33; 3.72-10.77); and onset of fever within 72 hours of hospital admission (2.20; 1.23-3.94) were independent predictors of central fever on multivariable analysis. The combination of negative cultures; absence of infiltrate on chest radiographs; diagnosis of subarachnoid hemorrhage, intraventricular hemorrhage, or tumor; and onset of fever within 72 hours of admission predicted central fever with a probability of .90. CONCLUSIONS AND RELEVANCE: We provide a reliable model to differentiate central fever from infectious fever in critically ill neurologic patients, allowing clinicians to select patients in whom antibiotics may be safely discontinued despite ongoing fever.

Refractory intracranial hypertension due to fentanyl administration following closed head injury.

BACKGROUND: Although the effects of opioids on intracranial pressure (ICP) have long been a subject of controversy, they are frequently administered to patients with severe head trauma. We present a patient with an uncommon paradoxical response to opioids. CASE REPORT: A patient with refractory intracranial hypertension after closed head injury was managed with standard medical therapy with only transient decreases in the ICP. Only after discontinuation of opiates did the ICP become manageable without metabolic suppression and rescue osmotic therapy, implicating opiates as the etiology of refractory intracranial hypertension in this patient. CONCLUSION: Clinicians should consider opioids as a contributing factor in malignant intracranial hypertension when findings on neuroimaging do not explain persistent and refractory intracranial hypertension.

Successful delayed thrombolysis for cerebral venous and dural sinus thrombosis: a case report and review of the literature.

Cerebral venous and dural sinus thrombosis (CVDST) is a rare but not uncommon life-threatening disease accounting for less than 1% of stroke, affecting people of any age group, predominantly the extremes of age. CVDST carries a variable prognosis: although the majority of cases are associated with complete recovery, outcome may be fatal in less than 10% of patients. Thrombolysis has been widely used in CVDST in patients with rapidly deteriorating symptoms who fail to improve despite adequate anticoagulation, but the exact therapeutic time window remains unclear. We report a case of CVDST with rapid clinical deterioration despite therapeutic anticoagulation treated with direct endovascular thrombolysis with intravenous recombinant tissue plasminogen activator 1 week after presentation with complete recovery, and we present a review of the literature on the efficacy and safety of thrombolysis in CVDST.