Seizure Assessment and Forecasting With Efficient Rapid-EEG: A Retrospective Multicenter Comparative Effectiveness Study.

BACKGROUND AND OBJECTIVES: Approximately 30% of critically ill patients have seizures, and more than half of these seizures do not have an overt clinical correlate. EEG is needed to avoid missing seizures and prevent overtreatment with antiseizure medications. Conventional-EEG (cEEG) resources are logistically constrained and unable to meet their growing demand for seizure detection even in highly developed centers. Brief EEG screening with the validated 2HELPS2B algorithm was proposed as a method to triage cEEG resources, but it is hampered by cEEG requirements, primarily EEG technologists. Seizure risk-stratification using reduced time-to-application rapid response-EEG (rrEEG) systems (∼5 minutes) could be a solution. We assessed the noninferiority of the 2HELPS2B score on a 1-hour rrEEG compared to cEEG. METHODS: A multicenter retrospective EEG diagnostic accuracy study was conducted from October 1, 2021, to July 31, 2022. Chart and EEG review performed with consecutive sampling at 4 tertiary care centers, included records of patients ≥18 years old, from January 1, 2018, to June 20, 2022. Monte Carlo simulation power analysis yielded n = 500 rrEEG; for secondary outcomes n = 500 cEEG and propensity-score covariate matching was planned. Primary outcome, noninferiority of rrEEG for seizure risk prediction, was assessed per area under the receiver operator characteristic curve (AUC). Noninferiority margin (0.05) was based on the 2HELPS2B validation study. RESULTS: A total of 240 rrEEG with follow-on cEEG were obtained. Median age was 64 (interquartile range 22); 42% were female. 2HELPS2B on a 1-hour rrEEG met noninferiority to cEEG (AUC 0.85, 95% CI 0.78-0.90, p = 0.001). Secondary endpoints of comparison with a matched contemporaneous cEEG showed no significant difference in AUC (0.89, 95% CI 0.83-0.94, p = 0.31); in false negative rate for the 2HELPS2B = 0 group (p = 1.0) rrEEG (0.021, 95% CI 0-0.062), cEEG (0.016, 95% CI 0-0.048); nor in survival analyses. DISCUSSION: 2HELPS2B on 1-hour rrEEG is noninferior to cEEG for seizure prediction. Patients with low-risk (2HELPS2B = 0) may be able to forgo prolonged cEEG, allowing for increased monitoring of at-risk patients. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that rrEEG is noninferior to cEEG in calculating the 2HELPS2B score to predict seizure risk.

Continuous Tissue Plasminogen Activator Infusion Using a Minimally Invasive Irrigating Catheter for the Treatment of Intraparenchymal Hemorrhage Within the Basal Ganglia: Case Reports.

BACKGROUND AND IMPORTANCE: Intraparenchymal hemorrhage (IPH) is a debilitating and highly morbid type of stroke with limited effective treatment modalities. Minimally invasive evacuation with tissue plasminogen activator (rt-PA) has demonstrated promise for mortality/functional improvements with adequate clot volume reduction. In this study, we report 2 cases of continuous rt-PA infusion using a closed circuit, dual lumen catheter, and irrigation system (IRRAflow) for IPH treatment. CLINICAL PRESENTATION: A 55-year-old man was admitted for acute onset left hemiparesis; he was found to have right basal ganglia IPH. He was treated with continuous rt-PA irrigation using the IRRAflow device, at a rate of 30 mL/h for 119 hours, with a total volume reduction of 87.8 mL and post-treatment volume of 1.2 mL. At 3-month follow-up, he exhibited a modified Rankin score of 4 and improved hemiparesis. A 39-year-old woman was admitted for acute onset left facial droop, left hemianopsia, and left hemiparesis; she was diagnosed with a right basal ganglia IPH. She was treated with drainage and continuous rt-PA irrigation at 30 mL/h for 24 hours, with a total hematoma volume reduction of 41 mL and with a final post-treatment volume of 9.1 mL. At 3-month follow-up, she exhibited a modified Rankin score of 3 with some improvement in left hemiparesis. CONCLUSION: Continuous rt-PA infusion using a minimally invasive catheter with saline irrigation was feasible and resulted in successful volume reduction in 2 patients with IPH. This technique is similar to the Minimally Invasive Surgery Plus rt-PA for Intracerebral Hemorrhage Evacuation (MISTIE) approach but offers the potential advantages of less breaks in the sterile circuit, continuous intracranial pressure monitoring, and may provide more efficient clot lysis compared with intermittent bolusing.

Primary meningeal melanocytoma of the cerebellopontine angle associated with ipsilateral nevus of Ota: A case report.

BACKGROUND: Cerebellopontine angle represents a complex anatomical area of the brain. A cerebellopontine angle lesion could be a vestibular schwannoma, meningioma, epidermoid cyst, or less likely, arachnoid cyst, metastasis, lower cranial nerves schwannoma, lipoma, hemangioma, paraganglioma, or vertebra-basilar dolichoectasia. Primary meningeal melanocytoma is a rare neoplasm, especially when it occurs at the cerebellopontine angle. Nevus of Ota (aka oculodermal melanocytosis) is a hyperpigmentation along the distribution of the ophthalmic and maxillary branches of trigeminal nerve; it occurs due to entrapment of melanocytes at the upper third of the dermis. It may not present at birth and may show up at puberty. CASE DESCRIPTION: We describe a case of primary meningeal melanocytoma of the cerebellopontine angle associated with nevus of Ota in a 46-year-old male patient presented with 7-day history of left arm weakness and vertigo. Computed tomography and MRI showed right-sided cerebellopontine angle mass, which was resected. Histopathology confirmed the meningeal melanocytic lesion and revealed its nature. CONCLUSION: Primary meningeal melanocytoma of the brain is a rare but benign tumor; the association between meningeal melanocytoma and nevus of Ota is also rare and possibly explained by their common embryonic origin from neural crest cells. There are six cases reported so far in literature including our case for meningeal melanocytoma associated with nevus of Ota.