Intrapulmonary and Intracardiac Shunts in Adult COVID-19 Versus Non-COVID Acute Respiratory Distress Syndrome ICU Patients Using Echocardiography and Contrast Bubble Studies (COVID-Shunt Study): A Prospective, Observational Cohort Study.

OBJECTIVES: Studies have suggested intrapulmonary shunts may contribute to hypoxemia in COVID-19 acute respiratory distress syndrome (ARDS) with worse associated outcomes. We evaluated the presence of right-to-left (R-L) shunts in COVID-19 and non-COVID ARDS patients using a comprehensive hypoxemia workup for shunt etiology and associations with mortality. DESIGN: Prospective, observational cohort study. SETTING: Four tertiary hospitals in Edmonton, Alberta, Canada. PATIENTS: Adult critically ill, mechanically ventilated, ICU patients admitted with COVID-19 or non-COVID (November 16, 2020, to September 1, 2021). INTERVENTIONS: Agitated-saline bubble studies with transthoracic echocardiography/transcranial Doppler ± transesophageal echocardiography assessed for R-L shunts presence. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were shunt frequency and association with hospital mortality. Logistic regression analysis was used for adjustment. The study enrolled 226 patients (182 COVID-19 vs 42 non-COVID). Median age was 58 years (interquartile range [IQR], 47-67 yr) and Acute Physiology and Chronic Health Evaluation II scores of 30 (IQR, 21-36). In COVID-19 patients, the frequency of R-L shunt was 31 of 182 COVID patients (17.0%) versus 10 of 44 non-COVID patients (22.7%), with no difference detected in shunt rates (risk difference [RD], -5.7%; 95% CI, -18.4 to 7.0; p = 0.38). In the COVID-19 group, hospital mortality was higher for those with R-L shunt compared with those without (54.8% vs 35.8%; RD, 19.0%; 95% CI, 0.1-37.9; p = 0.05). This did not persist at 90-day mortality nor after adjustment with regression. CONCLUSIONS: There was no evidence of increased R-L shunt rates in COVID-19 compared with non-COVID controls. R-L shunt was associated with increased in-hospital mortality for COVID-19 patients, but this did not persist at 90-day mortality or after adjusting using logistic regression.

Electroencephalogram patterns in critical care: A primer for acute care doctors.

Electroencephalograms are commonly ordered by acute care doctors but not always understood. Other reviews have covered when and how to perform electroencephalograms. This primer has a different, unique, and complementary goal. We review basic electroencephalogram interpretation and terminology for nonexperts. Our goal is to encourage common understanding, facilitate inter specialty collaboration, dispel common misunderstandings, and inform the current and future use of this precious resource. This primer is categorically not to replace the expert neurologist or technician. Quite the contrary, it should help explain how nuanced electroencephalogram can be, and why indiscriminate electroencephalogram is inappropriate. Some might argue not to teach nonexperts lest they overestimate their abilities or reach. We humbly submit that it is even more inappropriate to not know the basics of a test that is ordered frequently and resource intensive. We cover the characteristics of the "normal" electroencephalogram, electroencephalogram slowing, periodic epileptiform discharges (and its subtypes), burst suppression, and electrographic seizures (and its subtypes). Alongside characteristic electroencephalogram findings, we provide clinical pearls. These should further explain what the reporter is communicating and whether additional testing is beneficial. Along with teaching the basics and whetting the appetite of the general clinician, this resource could increase mutual understanding and mutual appreciation between those who order electroencephalograms and those who interpret them. While there is more to electroencephalogram than can be delivered via a single concise primer, it offers a multidisciplinary starting point for those interested in the present and future of this commonly ordered test.

Hippocampal and trigeminal nerve volume predict outcome of surgical treatment for trigeminal neuralgia.

BACKGROUND: Many medically-refractory trigeminal neuralgia patients are non-responders to surgical treatment. Few studies have explored how trigeminal nerve characteristics relate to surgical outcome, and none have investigated the relationship between subcortical brain structure and treatment outcomes. METHODS: We retrospectively studied trigeminal neuralgia patients undergoing surgical treatment with microvascular decompression. Preoperative magnetic resonance imaging was used for manual tracing of trigeminal nerves and automated segmentation of hippocampus, amygdala, and thalamus. Nerve and subcortical structure volumes were compared between responders and non-responders and assessed for ability to predict postoperative pain outcome. RESULTS: In all, 359 trigeminal neuralgia patients treated surgically from 2005-2018 were identified. A total of 34 patients met the inclusion criteria (32 with classic and two with idiopathic trigeminal neuralgia). Across all patients, thalamus volume was reduced ipsilateral compared to contralateral to the side of pain. Between responders and non-responders, non-responders exhibited larger contralateral trigeminal nerve volume, and larger ipsilateral and contralateral hippocampus volume. Through receiver-operator characteristic curve analyses, contralateral hippocampus volume correctly classified treatment outcome in 82% of cases (91% sensitive, 78% specific, p = 0.008), and contralateral nerve volume correctly classified 81% of cases (91% sensitive, 75% specific, p < 0.001). Binomial logistic regression analysis showed that contralateral hippocampus and contralateral nerve volumes together classified outcome with 84% accuracy (Nagelkerke R2 = 65.1). CONCLUSION: Preoperative hippocampal and trigeminal nerve volume, measured on standard clinical magnetic resonance images, may predict early non-response to surgical treatment for trigeminal neuralgia. Treatment resistance in medically refractory trigeminal neuralgia may depend on the structural features of both the trigeminal nerve and structures involved in limbic components of chronic pain.

Immune Cell Infiltrates in Hippocampal Sclerosis: Correlation With Neuronal Loss.

Immune mechanisms have been increasingly recognized in the pathogenesis of hippocampal sclerosis (HS), but infiltration of cytotoxic T-cells and its pathological significance in patients with HS has not been explored. We examined 30 cases of surgically resected hippocampi, including 16 International League Against Epilepsy (ILAE) type 1, 9 ILAE type 2, 1 ILAE type 3 HS, and 4 ILAE No-HS, as well as 6 autopsy No-HS hippocampi. The HS hippocampi showed sparse to scattered CD8-positive T-cells, rare CD4-positive T-cells, and a modest increase in CD68-positive microglia/macrophages, which were significantly more numerous than those in the No-HS controls. The infiltration of CD8-positive T-cells was significantly greater in the CA1 subfield than other subfields of type 1 and type 2 HS. The numbers of CD8-positive T-cells positively correlated with those of CD4-positive T-cells; there was a lower ratio of CD4/CD8-positive T-cells. There were positive correlations between these cells and scores of neuronal loss but no significant correlation between the infiltration of these cells and epilepsy disease duration or age of epilepsy onset. These findings suggest that an autoimmune process may be involved in the pathogenesis of HS and infiltration of immune cells, particularly CD8-positive cytotoxic T-cells, may contribute to neuronal loss in HS.

Recommendations for the evaluation and management of observation services: a consensus white paper: the Society of Cardiovascular Patient Care.

Observation Services (OS) was founded by emergency physicians in an attempt to manage "boarding" issues faced by emergency departments throughout the United States. As a result, OS have proven to be an effective strategy in reducing costs and decreasing lengths of stay while improving patient outcomes. When OS are appropriately leveraged for maximum efficiency, patients presenting to emergency departments with common disease processes can be effectively treated in a timely manner. A well-structured observation program will help hospitals reduce the number of inappropriate, costly inpatient admissions while avoiding the potential of inappropriate discharges. Observation medicine is a complicated multidimensional issue that has generated much confusion. This service is designed to provide the best possible patient care in a value-based purchasing environment where quality, cost, and patient satisfaction must continually be addressed. Observation medicine is a service not a status. Therefore, patients are admitted to the service as outpatients no matter whether they are placed in a virtual or dedicated observation unit. The key to a successful observation program is to determine how to maximize efficiencies. This white paper provides the reader with the foundational guidance for observational services. It defines how to set up an observational service program, which diagnoses are most appropriate for admission, and what the future holds. The goal is to help care providers from any hospital deliver the most appropriate level of treatment, to the most appropriate patient, in the most appropriate location while controlling costs.

Gelastic seizures with dancing arising from the anterior prefrontal cortex.

AIM: This case report provides insight into the function of the anterior prefrontal cortex (aPFC), specifically Brodmann Area 10 (BA10), and its interconnectivity. METHOD: We present a 10-year-old patient with lesional epilepsy and ictal onset, localised to BA10 in the aPFC. RESULTS: Thirty-four seizures were recorded. All seizures involved a demonstration of elation with laughter that was associated with a variety of different patterns of complex motor behaviour that included performing specific celebratory movements and acting out a Michael Jackson dance move. Electrographically, the seizures were all stereotyped and arose from the right frontal region, followed by a distinct left temporal ictal rhythm that corresponded with the onset of the behaviours. The lesion in the right aPFC was identified as a mixed lesion with both dysembryoplastic neuroepithelial tumour cells and type II cortical dysplasia. CONCLUSION: The electrographic analysis and unique seizure semiology suggest a connection between the aPFC and the contralateral temporal lobe. This neural pathway appears to be involved in the activation of previously formed procedural memories, creating an intensely positive emotional experience.

Depth electrodes in pediatric epilepsy surgery.

BACKGROUND: The surgical removal of the epileptogenic zone in medically intractable seizures depends on accurate localization to minimize the neurological sequelae and prevent future seizures. To date, few studies have demonstrated the use of depth electrodes in a pediatric epilepsy population. Here, we report our study of pediatric epilepsy patients at our epilepsy center who were successfully operated for medically intractable seizures following the use of intracranial depth electrodes. In addition, we detail three individuals with distinct clinical scenarios in which depth electrodes were helpful and describe our technical approach to implantation and surgery. METHODS: We retrospectively reviewed 18 pediatric epilepsy patients requiring depth electrode studies who presented at the University of Alberta Comprehensive Epilepsy Program between 1999 and 2010 with medically intractable epilepsy. Patients underwent cortical resection following depth electrode placement according to the Comprehensive Epilepsy Program surgical protocols after failure of surface electroencephalogram and magnetic resonance imaging to localize ictal onset zone. RESULT: The ictal onset zone was successfully identified in all 18 patients. Treatment of all surgical patients resulted in successful seizure freedom (Engel class I) without neurological complications. CONCLUSION: Intracranial depth electrode use is safe and able to provide sufficient information for the identification of the epileptogenic zone in pediatric epilepsy patients previously not considered for epilepsy surgery.

Intelligence quotient is not affected by epilepsy surgery in childhood.

Epilepsy surgery is known to help children with intractable seizures. The effect of epilepsy surgery itself on cognition in childhood is less well studied. We report our experience at the University of Alberta Hospital on the effects of epilepsy surgery on cognition. All children undergoing epilepsy surgery at the Comprehensive Epilepsy Program from 1990-2005 were examined. Sixty-seven patients received both preoperative and postoperative neuropsychologic evaluations. We compared verbal, performance, and full scale intelligent quotients and the Child Behavioral Checklist preoperatively and postoperatively. Forty-eight patients demonstrated excellent surgical outcomes, with significant reductions in disabling seizures. Overall, no significant change occurred in neuropsychologic parameters examined after surgery. Epilepsy surgery in childhood offers excellent surgical outcomes for seizure control, and does not adversely affect intelligence quotient.

Discontinuation of antiepileptic drugs after pediatric epilepsy surgery.

In children with medically intractable seizures, epilepsy surgery is now a widely accepted option. Successful discontinuation of antiepileptic drugs after epilepsy surgery has been reported in adults, but rarely in children. Surgical outcome and need for antiepileptic drugs after temporal and extratemporal lobe resection were retrospectively reviewed for 80 pediatric patients from the Comprehensive Epilepsy Program at the University of Alberta. For 1 year after surgery, children were maintained on at least one antiepileptic drug. Antiepileptic drug discontinuation was attempted in all patients with a nonepileptic electroencephalogram after 1 year seizure-free. Less than half of the patients (44%) eventually relapsed without antiepileptic drugs. Of the 40 patients in the temporal lobe group, 13 (32%) relapsed without antiepileptic drugs, as did 22 of the 40 extratemporal lobe resection patients (55%). Success rates for antiepileptic drug discontinuation after surgery were higher in the temporal lobe than in the extratemporal lobe group. Long-term antiepileptic drugs are not necessary in all cases, and for many children medication can be withdrawn after epilepsy surgery.

Posterior resection for childhood epilepsy.

We reviewed our experience with posterior resection for intractable childhood epilepsy. Fifteen patients, seven males and eight females, were studied. Age of surgery was 18 months to 16 years. Nine patients had a parietal resection and six patients had an occipital resection. Surgical outcome was variable. Nine patients had an excellent outcome (Engel Class I or II), two patients had a poor outcome (Engel Class III), and four patients had a very poor outcome (Engel Class IV). Pathology at surgery included focal cortical dysplasias (4), brain tumors (4), tubers of tuberous sclerosis (2), cerebrovascular accidents (2), porencephalic cysts (1), and normal pathology (2). Complications included visual field loss in the occipital lobe patients (4/6). Posterior resection can be successful for children with intractable epilepsy originating in the parietal and occipital lobes. Invasive monitoring is necessary in some patients to establish the extent of the epileptic zone before surgery. A good surgical outcome is dependent on the presence of a circumscribed lesion on MRI and ability to surgically remove all the pathology. Visual abnormalities are an expected complication of surgery in the occipital lobe, but may improve over time.

Frontal lobe epilepsy in childhood.

Frontal lobe epilepsy is poorly understood and often unrecognized by health care workers caring for children. We sought to better characterize frontal lobe epilepsy in childhood and help delineate this condition from other nonepileptic events. We reviewed pediatric patients admitted to the Comprehensive Epilepsy Program at the University of Alberta Hospitals with a proven diagnosis of frontal lobe epilepsy. Twenty-two patients, 13 males and 9 females, were studied. Age of onset was variable from 10 months to 16 years (mean 7.5 years). Seizures were brief (30 seconds to 2 minutes), stereotypic, nocturnal (17/21), and frequent (3-22/night). Clinical features included explosive onset, screaming, agitation, stiffening, kicking or bicycling of the legs, and incontinence. The diagnosis of frontal lobe epilepsy was not made in any child before referral. The referring diagnosis was sleep disturbance (10), psychiatric problems (6), or other seizure types (6). Interictal electroencephalogram was usually normal (18/21). Long-term video electroencephalographic monitoring demonstrated frontal (9) or bifrontal (13) epileptic discharges. Magnetic resonance imaging was normal in most patients (18/21). Seizure control was difficult, with only half (11/21) the patients being controlled on medication. Three intractable patients went on to epilepsy surgery and became seizure-free. Frontal lobe epilepsy in childhood is a distinct epilepsy syndrome with characteristic features. The seizures are brief, stereotypic, nocturnal, and frequent. Electroencephalogram and magnetic resonance imaging are usually normal. The condition is often misdiagnosed as a sleep disorder or psychiatric problem. Seizures are difficult to control but may respond to carbamazepine, valproic acid, or epilepsy surgery.

Extratemporal resection for childhood epilepsy.

There have been relatively few studies reporting the safety, efficacy, and outcome in children undergoing extratemporal resection for epilepsy. We reviewed the pediatric cases of extratemporal resection for intractable epilepsy performed by the Comprehensive Epilepsy Program at the University of Alberta Hospitals between 1988-1998. Thirty-five patients were studied, 14 male and 21 female. The age at operation ranged from 6 months to 16 years. The operations included frontal excisions (12), parietal (8), occipital (4), hemispherectomies or multilobar resections (10), and one removal of a hypothalamic hamartoma. The pathology at surgery included patients with focal cortical dysplasia (8), brain tumors (6), neurocutaneous syndrome (7), Rasmussen's encephalitis (2), porencephalic cysts (4), hypothalamic hamartoma (1), and nonspecific gliosis (6). Twenty-four of 35 patients (68.5%) had an Engel Class I outcome after surgery and an additional six patients (11%) had a significant decrease in seizure frequency (Engel Class III). Complications were observed in two patients (5%) and there were no deaths. Extratemporal resection is a safe and effective treatment for children with intractable epilepsy. Overall, 68% of patients were seizure-free after surgery, although outcome may be dependent on site and pathology. A wide range of developmental pathology was observed including focal cortical dysplasia, brain tumors, and lesions with neurocutaneous syndromes. Many families reported improvement in behavior and psychosocial function after surgery.