Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know.

Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.

Deep Brain Stimulator (DBS) Artifact in the EEG of a Pediatric Patient.

We report the first case of deep brain stimulator (DBS) artifact in the EEG of a pediatric patient. Our case is a 7-year-old male with bilateral globus pallidus interna (GPi) DBS for whom the EEG recorded a rhythmic 7.5 Hz theta activity on EEG related to DBS artifact. This artifact was also appreciated as a monochromatic invariable frequency band over 7.5 Hz on density spectral array (DSA). This rhythmic artifact may mimic an ictal pattern and should be recognized as artifact in order to avoid unnecessary treatment with anti-seizure medications (ASM).

The Epilepsy Surgery Experience in Children With Infantile Epileptic Spasms Syndrome at a Tertiary Care Center in Canada.

Background: Infantile epileptic spasms syndrome is an epileptic encephalopathy, characterized by spasms, hypsarrhythmia, and developmental regression. Appropriately selected patients with infantile epileptic spasms syndrome may be candidates for epilepsy surgery. Methods: This is a single-center retrospective case series of children 0-18 years with a current or previous diagnosis of infantile epileptic spasms syndrome with a lesion on magnetic resonance imaging (MRI) and/or positron emission tomography scan who underwent epilepsy surgery at The Hospital for Sick Children (HSC) in Toronto, Canada. The records of 223 patients seen in the infantile epileptic spasms syndrome clinic were reviewed. Results: Nineteen patients met inclusion criteria. The etiology of infantile epileptic spasms syndrome was encephalomalacia in 6 patients (32%), malformations of cortical development in 12 patients (63%), and atypical hypoglycemic injury in 1 patient (5%). Nine patients (47%) underwent hemispherectomy, and 10 patients (53%) underwent lobectomy/lesionectomy. Three patients (16%) underwent a second epilepsy surgery. Fifteen patients (79%) were considered ILAE seizure outcome class 1 (completely seizure free; no auras) at their most recent follow-up visit. The percentage of patients who were ILAE class 1 at most recent follow-up decreased with increasing duration of epilepsy prior to surgery. Developmental outcome after surgery was improved in 14 of 19 (74%) and stable in 5 of 19 (26%) patients. Conclusions: Our study found excellent seizure freedom rates and improved developmental outcomes following epilepsy surgery in patients with a history of infantile epileptic spasms syndrome with a structural lesion detected on MRI brain. Patients who undergo surgery earlier have improved seizure freedom rates and improved developmental outcomes.

A snapshot of type two diabetes mellitus management in general practice prior to the introduction of diabetes Cycle of Care.

BACKGROUND: Diabetes is associated with complications, including coronary heart disease, stroke, kidney failure, blindness and amputation, and ultimately is a major cause of disability and death worldwide. Adherence to best practice guidelines is limited in unstructured diabetes management in primary care settings. AIMS: This study aims to establish what data was being collected in general practice prior to the introduction of the Cycle of Care, which is a proactive model of diabetes management introduced in Ireland. METHODS: Medical students in general practices with the University of Limerick Graduate Entry Medical School and their supervisors used practice software to collect quantitative data from the clinical records of patients with T2DM. RESULTS: The sample included 2696 patients with T2DM who had visited their GP in the previous year. During the 12 months studied, 18.5% of patients with T2DM attended an emergency department and 24% were admitted to hospital. The results of the documentation of three modifiable risk factors associated with T2DM were as follows: 49.5% had BMI documented, 51.7% had smoking status documented and 33.9% had alcohol consumption documented. Two hundred and fifty people were diagnosed with T2DM in the previous 12 months. Of these, 19% had been referred to a chiropodist and 23% to a dietician. CONCLUSIONS: This study provides a comprehensive snapshot of care in Irish general practice for patients with T2DM prior to the introduction of the Cycle of Care. Future research must investigate the impact of Cycle of Care on patient care in general practice.