Safety and Outcome of Admission to Step-Down Level of Care in Patients with Low-Risk Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis.

Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke, and it is associated with high morbidity and mortality. Patients with a spontaneous ICH are routinely admitted to an intensive care unit (ICU). However, an ICU is a valuable and limited resource, and not all patients may require this level of care. The authors conducted a systematic review and meta-analysis evaluating the safety and outcome of admission to a step-down level of care or stroke unit (SU) compared to intensive care in adult patients with low-risk spontaneous ICH. PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials and observational cohort studies. The Mantel-Haenszel method or inverse variance, as applicable, was applied to calculate an overall effect estimate for each outcome by combining the specific risk ratio (RR) or standardized mean difference. Risk of bias was analyzed using the Newcastle-Ottawa Scale. The protocol was registered in PROSPERO (CRD42023481915). The primary outcome examined was in-hospital mortality. Secondary outcomes were unfavorable short-term outcome, length of hospital stay, and (re)admission to the ICU. Five retrospective cohort studies involving 1347 patients were included in the qualitative analysis. Two of the studies had severity-matched groups. The definition of low-risk ICH was heterogeneous among the studies. Admission to an SU was associated with a similar rate of mortality compared to admission to an ICU (1.4% vs. 0.6%; RR 1.66; 95% confidence interval [CI] 0.24-11.41; P = 0.61), a similar rate of unfavorable short-term outcome (14.6% vs. 19.2%; RR 0.77; 95% CI 0.43-1.36; P = 0.36), and a significantly shorter mean length of stay (standardized mean difference - 0.87 days; 95% CI - 1.15 to - 0.60; P < 0.01). Risk of bias was low to moderate for each outcome. The available literature suggests that a select subgroup of patients with ICH may be safely admitted to the SU without affecting short-term outcome, potentially saving in-hospital resources and reducing length of stay. Further studies are needed to identify specific and reliable characteristics of this subgroup of patients.

Clinical Characteristics, Imaging Findings, and Outcomes of Cerebral Air Embolism.

BACKGROUND: Arterial cerebral air embolism (CAE) is an uncommon but potentially catastrophic event. Patients can present with focal neurologic deficits, seizures, or coma. They may be treated with hyperbaric oxygen therapy. We review the causes, radiographic and clinical characteristics, and outcomes of patients with CAE. METHODS: We performed a retrospective chart review via an existing institutional database at Mayo Clinic to identify patients with arterial CAE. Demographic data, clinical characteristics, and diagnostic studies were extracted and classified on predefined criteria of diagnostic confidence, and descriptive and univariate analysis was completed. RESULTS: Fifteen patients met criteria for inclusion in our study. Most presented with focal deficits (80%) and/or coma (53%). Seven patients (47%) had seizures, including status epilepticus in one (7%). Five presented with increased muscle tone at the time of the event (33%). Computed tomography (CT) imaging was insensitive for the detection of CAE, only identifying free air in 4 of 13 who underwent this study. When obtained, magnetic resonance imaging typically showed multifocal areas of restricted diffusion. Six patients (40%) were treated with hyperbaric oxygen therapy. Age, Glasgow Coma Scale score at nadir, and use of hyperbaric oxygen therapy were not associated with functional outcome at 1 year in our cohort. Twenty-six percent of patients had a modified Rankin scale score of 0 one year after the event, and functional improvement over time was common after discharge. CONCLUSIONS: A high index of clinical suspicion is needed to identify patients with CAE because of low sensitivity of free air on CT imaging and nonspecific clinical presentation. Acute alteration of consciousness, seizures, and focal signs occur frequently. Because improvement over time is possible even among patients with severe presentation, early prognostication should be approached with caution.

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

BACKGROUND: Patients 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. METHODS: We 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. RESULTS: Even 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. CONCLUSIONS: Radiographic 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.

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.

Neurology Education for Critical Care Fellows Using High-Fidelity Simulation.

BACKGROUND: Simulation is becoming a more common modality in medical education. The data regarding effectiveness of simulation in critical care neurology education are limited. METHODS: We administered a three-scenario simulation course to critical care fellowship trainees at a large academic medical center as a part of their core curriculum requirement. Pre- and posttests assessing medical knowledge and trainee confidence in managing neurologic disease were completed by all trainees. Overall satisfaction and effectiveness were evaluated following the course. Change in trainee knowledge and confidence before and after the course was assessed for improvement. RESULTS: Sixteen trainees completed the simulation course. Prior to completion, medical knowledge was 5.2 ± 0.9 (of 8 possible correct answers) and following the course was 6.4 ± 1.3 (p = 0.002). Overall confidence improved from 15.4 ± 4.9 (of 30 possible points) to 20.7 ± 3.3 (p = <0.0001). Confidence was significantly improved for neurologic diseases directly assessed during the course (p = <0.0001) as well as for those not directly assessed (p = 0.004). CONCLUSIONS: Simulation is an effective means of neurologic education for critical care trainees, with improvement in both medical knowledge and trainee confidence after completion of a three-scenario simulation experience. This course ensures the exposure of critical care trainees to neurologic diseases that are required curricular milestones to successfully complete the fellowship training program.

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

BACKGROUND: Myoclonic 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. METHODS: Case series. RESULTS: We 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. CONCLUSIONS: On 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.

Steak and Stupor: seizures and E. coli O157 infection.

Neurological complications of haemolytic uraemic syndrome (HUS) include altered states of consciousness, seizures, ischaemic stroke and encephalopathy. Adult-onset HUS is uncommon, and there is only a limited literature reporting neurological complications in this population. We report an adult with Shiga toxin-associated HUS complicated by focal-onset non-convulsive status epilepticus, who made a full neurological recovery.

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.

Compound Muscle Action Potential and Myosin-Loss Pathology in Patients With Critical Illness Myopathy: Correlation and Prognostication.

BACKGROUND AND OBJECTIVES: Prolonged compound muscle action potential (CMAP) duration and preferential loss of myosin are considered the diagnostic hallmarks of critical illness myopathy (CIM); however, their correlation and prognostic values have not been studied. We aimed to investigate the correlation between CMAP duration and myosin loss and their effect on mortality by comparing between patients with CIM with and without myosin loss. METHODS: We searched the Mayo Clinic Electromyography Laboratory databases (1986-2021) for patients diagnosed with CIM on the basis of prolonged distal CMAP durations (>15 msec in fibular motor nerve studies recording over the tibialis anterior or >8 msec in other motor nerves) and needle EMG findings compatible with myopathy. Electrodiagnostic studies were generally performed within 24 hours after weakness became noticeable. We included only patients who underwent muscle biopsy. Clinical, electrophysiologic, and myopathologic data were reviewed. We conducted myosin/actin ratio analysis when muscle tissue was available. We used the Fisher exact test for categorical data comparisons and the Mann-Whitney 2-tailed test for continuous data. We applied the Kaplan-Meier technique to analyze survival rates. RESULTS: Twenty patients (13 female patients) were identified [median age at diagnosis of 62.5 years (range: 19-80 years)]. The median onset of weakness was 24 days (range: 1-128) from the first day of intensive care unit admission. Muscle biopsy showed myosin loss in 14 patients, 9 of whom had >50% of myofibers affected (high grade). Type 2 fiber atrophy was observed in 19 patients, 13 of whom also had myosin loss. Patients with myosin loss had higher frequency of steroid exposure (14 vs 3; p = 0.004); higher median number of necrotic fibers per low-power field (2.5 vs 1, p = 0.04); and longer median CMAP duration (msec) of fibular (13.4 vs 8.75, p = 0.02), tibial (10 vs 7.8, p = 0.01), and ulnar (11.1 vs 7.95, p = 0.002) nerves compared with those without. Only patients with high-grade myosin loss had reduced myosin/actin ratios (<1.7). Ten patients died during median follow-up of 3 months. The mortality rate was similar between patients with and without myosin loss. Patients with high-grade myosin loss had a lower overall survival rate than those with low-grade or no myosin loss, but this was not statistically significant (p = 0.05). DISCUSSION: Myosin loss occurred in 70% of the patients with CIM with prolonged CMAP duration. Longer CMAP duration predicts myosin-loss pathology. The extent of myosin loss marginally correlates with the mortality rate. Our findings highlight the potential prognostic values of CMAP duration and myosin loss severity in predicting disease outcome.

Etiologies and Utility of Diagnostic Tests in Trigeminal Neuropathy.

OBJECTIVE: To evaluate the utility of diagnostic studies in identifying treatable etiologies of trigeminal neuropathy (TNP). PATIENTS AND METHODS: We performed a review of consecutive patients with nontraumatic, noniatrogenic TNP seen at Mayo Clinic between January 1, 2000, and August 31, 2019. Patients were excluded if they had trigeminal neuralgia without neuropathy or if their diagnostic work-up had been completed elsewhere. Data were analyzed to determine which diagnostic studies were most useful in identifying treatable etiologies. RESULTS: In total, 439 patients were included. The mean ± SD age was 56.3±13.6 years and 285 (64.9%) were female. Among the 180 cases in which an etiology was identified (41.0%), neoplasms were causative in 76 (42.2%), while specific connective tissue diseases were implicated in 71 (39.4%). Bilateral TNP (n=83) was associated with the presence of underlying connective tissue disease (P<.01). Identification of etiology was made by magnetic resonance imaging in 88 cases (48.8%), by abnormal connective tissue disease cascades combined with rheumatology consultation in 42 (23.3%), by a previously known connective tissue disorder in 30 (16.7%), and by abnormal connective tissue disease cascades alone in 8 (4.4%). Among the 439 study patients, electromyography was performed in 211 (48.1%) and lumbar puncture in 139 (31.7%), but their diagnostic utility was low. CONCLUSION: Underlying causes of nontraumatic, noniatrogenic TNP can be identified in approximately 40% of cases. Bilateral TNP is strongly associated with underlying connective tissue disease. Careful history taking, dedicated magnetic resonance imaging, and connective tissue panels have the greatest diagnostic utility. Electromyography and cerebrospinal fluid analysis are unlikely to elucidate treatable etiologies of TNP.

Subarachnoid hemorrhage from sudden gravitational changes.

Diffuse subarachnoid hemorrhage is commonly attributed to the rupture of intracranial aneurysms or other vascular malformations. Non-aneurysmal hemorrhages often have a characteristic pattern or clear mechanism (e.g. trauma) with an often more benign clinical course. We report the case of a diffuse non-aneurysmal subarachnoid hemorrhage due to sudden gravitational changes encountered during complex airflight maneuvers, complicated by hydrocephalus and cerebral vasospasm. This case illustrates a rare phenomenon that may again be encountered in the future with the advent and advancement of civilian spaceflight.

A Case Report of "Propofol Frenzy": Anesthetic Considerations for a Severe Propofol-Induced Neuroexcitation Reaction.

Propofol "frenzy" is considered a severe propofol-induced neuroexcitatory reaction involving nonepileptic spells of extremity thrashing, marked agitation, irregular eye movements, and impaired consciousness. Patients with propofol neuroexcitation present unique challenges for anesthesia providers due to underrecognition, lack of diagnostic tests, and differentiating from other comparable disorders that require medications that can exacerbate symptoms. We present a case of a healthy young patient whose postoperative course was complicated by propofol frenzy and functional limb paralysis following hip surgery with a spinal anesthetic and propofol sedation. This case highlights anesthesia considerations for propofol frenzy and discusses dexmedetomidine as a promising modality for prompt management.

A Disclosure About Death Disclosure: Variability in Circulatory Death Determination.

INTRODUCTION: Circulatory-respiratory death declaration is a common duty of physicians, but little is known about the amount of education and physician practice patterns in completing this examination. METHODS: An online survey of physicians was conducted evaluating the rate of formal training and specific examination techniques used in the pronouncement of circulatory-respiratory death. Data, including the level of practice, training received in a formal death declaration, and examination components, were collected. RESULTS: Respondents were attending physicians (52.4%), residents (30.2%), fellows (10.7%), and interns (6.7%). Most respondents indicated they had received no formal training in death pronouncement; however, most reported self-perceived competence. When comparing examination components used by the study's cohort, 95 different examination combinations were used for death pronouncement. CONCLUSIONS: Formal training in death pronouncement was uncommon and clinical practice varied. Implementation of formal training and standardization of the examination are necessary to improve physician competence and reliability in death declarations.

Evaluator Agreement in Medical Student Assessment Across a Multi-Campus Medical School During a Standardized Patient Encounter.

PURPOSE: Class rank and clerkship grades impact a medical student's residency application. The variability and inter-rater reliability in assessment across multiple clinical sites within a single university system is unknown. We aimed to determine if medical student assessment across medical school campuses is consistent when using a standardized scoring rubric. DESIGN/METHODS: Attending physicians who participate in assignment of clerkship grades for neurology from three separate clinical campuses of the same medical school observed 10 identical standardized patient encounters completed by third year medical students during the 2017-2018 academic year. Scoring was completed using a standardized rubric. Descriptive analysis and intra-rater comparisons were completed. Evaluations as a part of this study were completed in 2018. RESULTS: Of 50 possible points for the patient encounter, the median score among all medical students and all evaluators was 43 (IQR 40, 45.5). Evaluator number 1 provided a statistically significant lower overall score as compared to evaluators 2 and 3 (p = 0.0001 and p = 0.0006, respectively), who were consistently similar in their overall medical student assessment (p = 0.46). Overall agreement between evaluators was good (ICC = 0.805, 95% CI 0.36-0.95) and consistency was excellent (ICC = 0.91, 95% CI 0.75-0.97). CONCLUSIONS: Medical student evaluation across multiple clinical campus sites via observation of identical standardized patient encounters and use of a standardized scoring rubric generally demonstrated good inter-rater agreement and consistency, but the small variation seen may affect overall clerkship scores.

Use of diffusion-weighted imaging to distinguish seizure-related change from limbic encephalitis.

OBJECTIVE: To determine whether diffusion-weighted imaging (DWI) can help differentiate peri-ictal signal abnormality from limbic encephalitis (LE) among patients with medial temporal lobe T2-hyperintensity. METHODS: We retrospectively identified patients with peri-ictal medial temporal lobe T2-hyperintensity using a Mayo Clinic database, and reviewed their DWI to look for unique diffusion restriction patterns. We then identified patients with medial temporal lobe T2-hyperintensity and LE, and reviewed their DWI to see if these patterns were ever present. Presence of diffusion restriction patterns was confirmed by a blinded neuro-radiologist. RESULTS: We identified 10 patients without LE who had peri-ictal unilateral medial temporal lobe T2-hyperintensity, ipsilateral to focal seizure onset. Nine of 10 (90%) had at least one of two diffusion restriction patterns potentially unique to seizure activity; four had gyriform hippocampal diffusion restriction ("Pattern 1"), three had diffuse hippocampal diffusion restriction that spared the most medial temporal lobe structures ("Pattern 2"), and two had both diffusion restriction patterns. The median patient age was 62 years (range 2-76 years) and 3/9 (33%) were female. In comparison, among patients with medial temporal lobe T2-hyperintensity and LE, only 5/57 (9%) had one of the diffusion restriction patterns ("Pattern 2") identified (P < 0.0001); all five had seizures reported. CONCLUSIONS: In patients with medial temporal lobe T2-hyperintensity and one of the diffusion restriction patterns described herein, the signal abnormality may be a peri-ictal phenomenon rather than indicative of LE and should prompt investigation for seizure. Even in patients with LE, these patterns should raise concern for seizure.