Ketamine for empiric treatment of cortical spreading depolarization after subdural hematoma evacuation.

BACKGROUND: It is widely known that some patients surgically treated for subdural hematoma (SDH) experience neurologic deficits not clearly explained by the acute brain injury or known sequelae like seizures. There is increasing evidence that cortical spreading depolarization (CSD) may be the cause. A recent article demonstrated that CSD occurred at a rate of 15 % and was associated with neurological deterioration in a subset of patients following chronic subdural hematoma evacuation. Furthermore, CSD can lead to ischemia leading to worsening neurologic deficits. CSD is usually detected on electrocorticography (ECoG) and needs cortical strip electrode placement with equipment and expertise that may not be readily available. CASE DESCRIPTION: We report three cases of patients with subdural hematoma (SDH) not undergoing ECoG in whom CSD was suspected to be the cause of their neurologic deficits post evacuation. Extensive workup including neuroimaging and electroencephalography (EEG) were inconclusive. Patients were subsequently treated with ketamine infusion and had resultant neurological recovery. CONCLUSIONS: Ketamine infusion can help reverse neurologic deficits in patients with SDH in whom the deficits are not explained by neuroimaging or electrographic seizure. CSD is a known phenomenon that can result in neurological injury and must remain in the differential diagnosis of such patients. Though only limited cases are discussed (n = 3), this small case series provides the basis for conducting clinical trials evaluating the efficacy of ketamine in improving functional outcome in brain-injured patients demonstrating evidence of CSD.

Portable Magnetic Resonance Imaging for ICU Patients.

OBJECTIVES: Patients in ICUs often require neuroimaging to rule out a wide variety of intracranial problems. CT may be available in the ICU itself, but MRI has greater sensitivity for many conditions that affect the brain. However, transporting patients who are on ventilators and other life-sustaining devices is a labor-intensive process and involves placing the patient at risk for adverse events. This is a report of portable MRI in a clinical setting. DESIGN: This is a prospective, nonrandomized, observational study at one institution, utilizing a 0.064-T, self-shielding, portable MRI in ventilated patients in an ICU setting. SETTING: Academic medical center. PATIENTS: Nineteen patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection. Patients selected for imaging had any of the following: 1) unexplained encephalopathy or coma, 2) seizures, 3) focal neurologic deficit, or 4) abnormal head CT. Imaging was performed in each patient's ICU room with a portable, self-shielding, 0.064-T MRI. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 19 patients, 20 MRI scans in seven ICUs were acquired between April 13, 2020, and April 23, 2020. No adverse events to patients or staff from MRI acquisition were reported. In 12 patients, abnormal findings were seen, which included increased fluid attenuated inversion recovery signal (n = 12), hemorrhage (n = 3), and diffusion-weighted imaging positivity (n =3). Imaging led to changes in clinical management in five patients. CONCLUSIONS: In this case series of patients, use of portable MRI has been found to be safe, feasible, and led to changes in clinical management based on imaging results. However, future studies comparing results with other imaging modalities are required to understand fully the extent of its clinical utility.

Behavioral Changes Without Respiratory Symptoms as a Presenting Sign of COVID-19 Encephalitis.

The clinical presentation, diagnosis, and treatment of coronavirus disease 2019 (COVID-19) encephalitis are still being characterized. Few case reports describing COVID-19 encephalitis are available in the literature. We present a case of COVID-19 encephalitis who presented with behavioral disturbances without respiratory symptoms.

Effect of cesarean section on the risk of perinatal transmission of hepatitis C virus from HCV-RNA+/HIV- mothers: a meta-analysis.

BACKGROUND: Hepatitis C virus (HCV) vertical transmission is considered the main route of HCV infection in children. Some authors have stated that cesarean section (C/S) can reduce perinatal HCV transmission. However, the study findings are heterogeneous and high-quality studies are lacking. AIMS: To evaluate the effect of mode of delivery on the risk of perinatal mother-to-infant transmission of HCV. METHODS: Only the peer-reviewed published studies that compared perinatal transmission rate of HCV in elective or emergency cesarean section with vaginal delivery in HCV-RNA+/HIV- mothers were included. We applied the random effect model of DerSimonian and Laird method with heterogeneity and sensitivity analyses. RESULTS: We identified 8 studies that involved 641 unique mother-infant pairs which fulfilled our inclusion criteria. Aggregation of study results did not show a significant decrease in HCV vertical transmission among study (mothers who underwent C/S) versus control (mothers who gave birth vaginally) patients [pooled odds ratio, 1.1 (95% CI 0.45-2.67)]. The P value was 0.35 for our test of heterogeneity. CONCLUSIONS: Our meta-analysis suggests that C/S does not decrease perinatal HCV transmission from HCV-RNA+/HIV- mothers to infants.