Seizures and the neurosurgical intensive care unit.

The cause of seizures in the neurosurgical intensive care unit (NICU) can be categorized as emanating from either a primary brain pathology or from physiologic derangements of critical care illness. Patients are typically treated with parenteral antiepileptic drugs. For early onset ICU seizures that are easily controlled, data support limited treatment. Late seizures have a more ominous risk for subsequent epilepsy and should be treated for extended periods of time or indefinitely. This review ends by examining the treatment algorithms for simple seizures and status epilepticus and the role newer antiepileptic use can play in the NICU.

Status epilepticus: an update.

Status epilepticus (SE) still results in significant mortality and morbidity. Whereas mortality depends mainly on the age of the patient as well as the cause, morbidity is often due to the myriad of complications that occur during prolonged admission to an intensive care environment. Although SE is a clinical diagnosis in most cases (convulsant), its treatment requires support by continuous electroencephalographic recording to ensure cessation of potential nonconvulsive elements of SE. Treatment has recently changed to incorporate four stages and must be initiated at the earliest possible time.

Developing a culture of safety in the epilepsy monitoring unit: a retrospective study of safety outcomes.

This study retrospectively reviewed 971 consecutive admissions to our epilepsy monitoring unit (EMU) from July 2007 to May 2011 to compare falls and missed seizures before and after implementing stricter safety processes in May 2009. New safety processes included enhanced staff education, a falls prevention signed contract with patient/family, observation of video-EEG monitors only by EEG technologists, hourly nurse rounding, standby assistance for hygiene needs, and immediate review of adverse events. Wilcoxon's two-sample tests were used for statistical analysis of the two groups. Reduced events between pre-intervention (492 patients) and post-intervention (479 patients) were significant for missed seizures (26 pre- vs 6 post-intervention, p=0.009) but not for falls (12 pre- vs 7 post-intervention, p=0.694). Intensive safety efforts in the EMU produced a 15% reduction in the fall rate per 1000 patient days and a 77% decrease in missed seizures. This study shows stricter safety processes help improve EMU patient safety.

An overview of third-generation antiseizure drugs: Clobazam, lacosamide, rufinamide, and vigabatrin.

Four antiseizure drugs have been approved in the United States since 2008. Clobazam, a 1,5-benzodiazepine, was approved in October 2011 as an adjunctive therapy for Lennox-Gastaut syndrome (LGS) in patients 2 years and older. Lacosamide, an amino acid that selectively enhances the slow inactivation of voltage-gated sodium channels, was approved in October 2008 as an add-on therapy for partial onset seizures in patients 17 years and older. Rufinamide, a triazole derivative, was approved in November 2008 as an adjunctive therapy for LGS in patients 4 years and older. Vigabatrin, an irreversible inhibitor of GABA transaminase, was approved in August 2009 for the treatment of infantile spasms in children ages 1 month to 2 years and intractable complex partial seizures in adults.

Withdrawal of life support in critically ill neurosurgical patients and in-hospital death after discharge from the neurosurgical intensive care unit. Clinical article.

OBJECT: The aim of this study was to examine the variables influencing the mode and location of death in patients admitted to a neurosurgical intensive care unit (NICU), including the participation of a newly appointed neurointensivist (NI). METHODS: Data from all patients admitted to a university hospital NICU were prospectively collected and compared between 2 consecutive 19-month periods before and after the appointment of an NI. RESULTS: One thousand eighty-seven patients were admitted before and 1279 after the NI's appointment. The withdrawal of life support (WOLS) occurred in 52% of all cases of death. Death following WOLS compared with survival was independently associated with an older patient age (OR 1.04/year, 95% CI 1.03-1.05), a higher University Hospitals Consortium (UHC) expected mortality rate (OR 1.05/%, 95% CI 1.04-1.07), transfer from another hospital (OR 3.7, 95% CI 1.6-8.4) or admission through the emergency department (OR 5.3, 95% CI 2.4-12), admission to the neurosurgery service (OR 7.5, 95% CI 3.2-17.6), and diagnosis of an ischemic stroke (OR 5.4, 95% CI 1.4-20.8) or intracerebral hemorrhage (OR 5.7, 95% CI 1.9-16.7). On discharge from the NICU, 54 patients died on the hospital ward (2.7% mortality rate). A younger patient age (OR 0.94/year, 95% CI 0.92-0.96), higher UHC-expected mortality rate (OR 1.01/%, 95% CI 1-1.03), and admission to the neurosurgery service (OR 9.35, 95% CI 1.83-47.7) were associated with death in the NICU rather than the ward. There was no association between the participation of an NI and WOLS or ward mortality rate. CONCLUSIONS: The mode and location of death in NICU-admitted patients did not change after the appointment of an NI. Factors other than the participation of an NI-including patient age and the severity and type of neurological injury-play a significant role in the decision to withdraw life support in the NICU or dying in-hospital after discharge from the NICU.

A survey of neurologists' views on epilepsy surgery and medically refractory epilepsy.

There is a 20-year delay between the diagnosis of epilepsy and surgical treatment. The aim of this study was to describe the different views held by neurologists regarding refractory epilepsy that may contribute to the delay in referring patients for epilepsy surgery. Neurologists in Michigan were mailed a 10-item survey inquiring about their definition of medically refractory epilepsy and their decision-making process in referring patients for epilepsy surgery. Eighty-four neurologists responded (20%). The majority defined medically refractory epilepsy as failure of three monotherapy antiepileptic drug (AEDs) trials and at least two polytherapy trials. Nineteen percent responded that all approved AEDs had to fail before a patient could be defined as medically refractory. Eighty-two percent of the respondents had referred patients for epilepsy surgery. Almost 50% were not satisfied with the level of communication from epilepsy centers. One-third reported serious complications resulting from surgery. These findings suggest that further education and improved communication from comprehensive epilepsy centers may shorten the time to referral and ultimately improve the lives of patients with epilepsy.

Vasovagal syncope misdiagnosed as epilepsy for 17 years: prime importance of clinical history.

Distinguishing epilepsy from syncope often can be challenging. We report a case of a 20-year-old patient with presumed refractory epilepsy since the age of 3 years. Although the clinical suspicion of syncope was raised at the age of 9 years, key historic features were not identified, cardiac work-up was not pursued and despite lack of electrographic evidence of epilepsy, he received anticonvulsant treatment. During his presurgical evaluation for "refractory epilepsy", one typical event was captured that was associated with asystole and normal electroencephalogram. The diagnosis of vasodepressor syncope was made and anticonvulsant medication was discontinued. With this case report, we would like to emphasize the importance of a meticulous history and the need to perform continuous video electroencephalographic with simultaneous electrocardiographic recordings in the evaluation of paroxysmal events with atypical presentation. [Published with video sequences].

Impact of a neurointensivist on outcomes in patients with head trauma treated in a neurosciences intensive care unit.

OBJECT: The aim of this study was to evaluate the impact of a newly appointed neurointensivist on outcomes in head-injured patients in the neurological/neurosurgical intensive care unit (NICU). METHODS: The mortality rate, length of stay (LOS), and discharge disposition of all patients with head trauma who had been admitted to a 10-bed tertiary care university hospital NICU were compared between two 19-month periods, before and after the appointment of a neurointensivist. Data regarding these patients were collected using the hospital database and the University HealthSystem Consortium (UHC) database. Samples of medical records were reviewed for Glasgow Coma Scale (GCS) score documentation. The authors analyzed data pertaining to 328 patients before and 264 after the neurointensivist's appointment. The unadjusted mean in-hospital mortality rate increased 1.1% in the after period, but this increase was significantly lower compared with the UHC-based expected increase of 8.1% in the mortality rate during the same period (p < 0.0001). The unadjusted mean mortality rate in the NICU decreased from 13.4 to 12.9% (relative mortality rate reduction 4%) and the mean NICU LOS increased from 3.1 to 3.6 days (relative NICU LOS increase 16%), both nonsignificantly. A 51% reduction in the NICU-associated mortality rate (p = 0.01), a 12% shorter hospital LOS (p = 0.026), and 57% greater odds of being discharged to home or to rehabilitation (p = 0.009) were found in the after period in multivariate models after controlling for baseline differences between the two time periods. Better documentation of the GCS score by the NICU team was also found in the after period (from 60.4 to 82%, p = 0.02). CONCLUSIONS: The institution of a neurointensivist-led team model had an independent, positive impact on patient outcomes, including a lower NICU-associated mortality rate and hospital LOS, improved disposition, and better chart documentation.

Documentation in medical records improves after a neurointensivist's appointment.

INTRODUCTION: Medical documentation is important for communication among health care professionals, research, legal defense, and reimbursement. Previous studies have indicated insufficient documentation by health care providers and resistance among physicians to comply with the new guidelines. Data in the intensive care unit (ICU) subpopulation are scarce. We examined the hypothesis that a newly appointed neurointensivist may alter documentation practices in a university hospital setting. METHODS: We sampled medical records of neurological intensive care unit (NICU) patients admitted with three specific diagnoses (head trauma, intracerebral hemorrhage, and subarachnoid hemorrhage) and examined changes in the documentation of important prognostic variables in two time periods: before and after the appointment of a neurointensivist. RESULTS: Overall, documentation improved from 32.5 to 57.5% (odds ratio, 95% confidence interval 2.8, 1.9-4.2) in the after period. Documentation using Glasgow Coma Scale, clot volume, Hunt & Hess scale, and Fisher's grade also improved significantly in each of the diagnoses examined in the after period. CONCLUSIONS: Our findings suggest that a major change was implemented in the NICU regarding documentation after a neurointensivist was appointed. Although the direct or indirect impact of the appointment was not clarified, these preliminary data warrant a prospective ICU study, which should determine the exact variables that play a role in documentation, how they change over time, and what reinforcing mechanisms can be used.

Vagus nerve stimulation therapy: 5-year or greater outcome at a university-based epilepsy center.

OBJECTIVE: This retrospective study documented long-term outcome of patients receiving vagus nerve stimulation (VNS) therapy for pharmacoresistant epilepsy. METHODS: Medical charts of 28 patients implanted for 5 years or longer were reviewed for changes in seizure frequency after 1 year of VNS therapy and at follow up, which ranged from 5 to 7 years. Numbers of antiepileptic drugs (AEDs) taken by the patients were also computed at 1 year and follow up. One patient had died and one had discontinued VNS therapy; data were available for 26 patients. RESULTS: The median percent change in seizure frequency from baseline increased from -28% (P = 0.0053, Wilcoxon signed-rank test) at 12 months to -72% (P < 0.0001) at follow up. Some patients whose seizure frequency was not reduced during the initial 12 months of VNS therapy did experience reductions in seizure frequency during the follow-up period. CONCLUSION: In this retrospective study, the effectiveness of VNS therapy increased over time. Physicians should be aware that response to VNS therapy may be delayed for some patients.

Emergent electroencephalogram in the intensive care unit: indications and diagnostic yield.

Our aim was to study the frequency and reasons an emergent electroencephalogram (EmEEG) is ordered in the ICUs compared to the hospital ward, examine its usefulness and find predictive variables for its results. We retrospectively identified all electroencephalograms ordered between December 1997 and March 2002 and performed within 1 hour. The tests ordered from four ICUs were compared with those ordered from the Ward beds, and predictive models were developed for the results based on clinical variables. We also compared the EmEEGs ordered by the Neuro-ICU to those from the other Units. The ICUs ordered 129 (49.4%) of all EmEEGs during the study period. The NICU ordered 32 tests. The most frequent reason for obtaining the test was to rule out status epilepticus (68.2%). The NICU ordered more frequently the test to exclude non-convulsive status than the other ICUs. Compared to non-ICU, ICU patients with head trauma or post cardiopulmonary arrest had more tests and patients with stroke fewer. Convulsive status epilepticus and generalized slowing were found more frequently in the ICUs, and normal EEG, interictal epileptiform activity or focal non-epileptic slowing were more frequent in the non-ICU cases. In at least 12.4% of ICU patients, the test was expected to lead to an anti-epileptic management change. Cardiopulmonary arrest and age were predictive of any epileptic activity on the EEG in ICU patients. In conclusion, in our institution EmEEG is ordered by the ICUs in two thirds of the cases to exclude status epilepticus. Although status epilepticus is confirmed more frequently in the ICUs than on the Ward, the most frequent finding remains generalized slowing, which is found in half of the ICU-ordered EmEEGs. A conservative estimation is that EmEEG will lead to medication change in at least 1 out of 8 ICU patients. Cardioopulmonary arrest is predictive of epileptic activity and a prolonged EmEEG may also increase the yield.

The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit.

OBJECTIVE: To evaluate the impact of a newly appointed neurointensivist on neurosciences intensive care unit (NICU) patient outcomes and quality of care variables. DESIGN: Observational cohort with historical controls. SETTING: Ten-bed neurointensive care unit in tertiary university hospital. PATIENTS: Mortality, length of stay (LOS), and discharge disposition of all patients admitted to the NICU were compared between two 19-month periods, before and after the appointment of a neurointensivist. Data regarding these patients were collected using the hospital database and the University Hospitals Consortium database. Individual patient medical records were reviewed for major complications and important prognostic variable documentation. INTERVENTIONS: Appointment of a neurointensivist. MEASUREMENTS AND MAIN RESULTS: We analyzed 1,087 patients before and 1,279 after the neurointensivist's appointment. The unadjusted in-hospital mortality decreased from 10.1% in the before to 9.1% in the after period (95% confidence interval, -1.3 to 3%, relative mortality reduction of 9.9%), but this decrease was significantly different than the expected increase of 1.4% in University Hospitals Consortium mortality during the same period (p = .048). The unadjusted mortality in the NICU decreased from 8% to 6.3% (95% confidence interval, -0.5 to 4, relative mortality reduction 21%) and mean NICU LOS from 3.5 to 2.9 days (95% confidence interval, 0.2 to 0.9, relative NICU LOS reduction 17%). A significant 42% reduction of the risk of death during the first 3 days of NICU admission (p = .003) and a 12% greater risk for NICU discharge (p = .02) were found in the after period in multivariate proportional hazard models. Discharge home increased from 51.7% in the before to 59.7% in the after period (95% confidence interval, 4 to 12, relative increase of 15%) and discharge to a nursing home decreased from 8.1% to 6.8% (95% confidence interval, -1 to 4, relative decrease of 16%). Although a higher total number of complications occurred in the after period, fewer of them occurred in the NICU (odds ratio, 0.2; 95% confidence interval, 0.08 to 0.54, p = .001); this may possibly be due to the better documentation by the NICU team in the after period. CONCLUSIONS: The institution of a neurointensivist-led team model was associated with an independent positive impact on patient outcomes, including a lower intensive care unit mortality, LOS, and discharge to a skilled nursing facility and a higher discharge home.

Simultaneous ERP and fMRI of the auditory cortex in a passive oddball paradigm.

Infrequent occurrences of a deviant sound within a sequence of repetitive standard sounds elicit the automatic mismatch negativity (MMN) event-related potential (ERP). The main MMN generators are located in the superior temporal cortex, but their number, precise location, and temporal sequence of activation remain unclear. In this study, ERP and functional magnetic resonance imaging (fMRI) data were obtained simultaneously during a passive frequency oddball paradigm. There were three conditions, a STANDARD, a SMALL deviant, and a LARGE deviant. A clustered image acquisition technique was applied to prevent contamination of the fMRI data by the acoustic noise of the scanner and to limit contamination of the electroencephalogram (EEG) by the gradient-switching artifact. The ERP data were used to identify areas in which the blood oxygenation (BOLD) signal varied with the magnitude of the negativity in each condition. A significant ERP MMN was obtained, with larger peaks to LARGE deviants and with frontocentral scalp distribution, consistent with the MMN reported outside the magnetic field. This result validates the experimental procedures for simultaneous ERP/fMRI of the auditory cortex. Main foci of increased BOLD signal were observed in the right superior temporal gyrus [STG; Brodmann area (BA) 22] and right superior temporal plane (STP; BA 41 and 42). The imaging results provide new information supporting the idea that generators in the right lateral aspect of the STG are implicated in processes of frequency deviant detection, in addition to generators in the right and left STP.