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1.
J Neurol ; 2020 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-32583056

RESUMO

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.

3.
J Neurol Sci ; 401: 1-4, 2019 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-30986702

RESUMO

BACKGROUND: Whether any treatment can stop fluctuations of stuttering lacunar syndromes (SLS) is unclear. Case reports have variably suggested effectiveness of intravenous thrombolysis, dual antiplatelet treatment, blood pressure augmentation and anticoagulation. We aim to describe our experience with different treatments used in in patients presenting with SLS and their effect on clinical fluctuations and functional outcome. METHODS: We collected demographic and clinical data of consecutive adult patients with SLS. Descriptive summaries were reported as median and inter-quartile range (IQR) for continuous variables and as frequencies and percentages for categorical variables. RESULTS: Forty patients (72 ±â€¯10 years, 36% female) were included. Pure motor syndrome (57%) was the most frequent clinical presentation. Clinical fluctuations stopped and the improvement was temporally related to aspirin-clopidogrel in 11/17 cases, intravenous thrombolysis in 4/6 cases, blood pressure augmentation in 1/3 cases and aspirin in 1/7 cases. Two patients continued fluctuating after IVT and later responded to blood pressure augmentation (n = 1) or aspirin-clopidogrel (n = 1). CONCLUSIONS: Aspirin plus clopidogrel may be followed by clinical improvement when intravenous thrombolysis is not an option. Blood pressure augmentation may beneficial as ad-on treatment in patients with labile blood pressure.

4.
Neurology ; 92(9): e888-e894, 2019 02 26.
Artigo em Inglês | MEDLINE | ID: mdl-30804063

RESUMO

OBJECTIVES: The degree of training and variability in the clinical brain death examination performed by physicians is not known. METHODS: Surveys were distributed to physicians (including physicians-in-training) practicing at 3 separate academic medical centers. Data, including level of practice, training received in completion of a brain death examination, examination components performed, and use of confirmatory tests were collected. Data were evaluated for accuracy in the brain death examination, self-perceived competence in the examination, and indications for confirmatory tests. RESULTS: Of 225 total respondents, 68 reported completing brain death examinations in practice. Most physicians who complete a brain death examination reported they had received training in how to complete the examination (76.1%). Seventeen respondents (25%) reported doing a brain death examination that is consistent with the current practice guideline. As a part of their brain death assessment, 10.3% of physicians did not report completing an apnea test. Of clinicians who obtain confirmatory tests on an as-needed basis, 28.3% do so if a patient breathes during an apnea test, a clinical finding that is not consistent with brain death. CONCLUSIONS: There is substantial variability in how physicians approach the adult brain death examination, but our survey also identified lack of training in nearly 1 in 4 academic physicians. A formal training course in the principles and proper technique of the brain death examination by physicians with expert knowledge of this clinical assessment is recommended.


Assuntos
Morte Encefálica/diagnóstico , Educação de Pós-Graduação em Medicina , Exame Neurológico/normas , Padrões de Prática Médica , Centros Médicos Acadêmicos , Anestesiologistas , Educação Médica , Humanos , Neurologistas , Neurocirurgiões , Guias de Prática Clínica como Assunto , Reflexo , Cirurgiões
6.
J Stroke Cerebrovasc Dis ; 27(6): 1565-1569, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29415814

RESUMO

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.


Assuntos
Hemorragia Cerebral/diagnóstico , Técnicas de Apoio para a Decisão , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Tronco Encefálico/fisiopatologia , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/fisiopatologia , Movimentos Oculares , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Atividade Motora , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Reflexo , Reprodutibilidade dos Testes , Mecânica Respiratória , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
7.
Neurocrit Care ; 28(3): 338-343, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29305758

RESUMO

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.


Assuntos
Fossa Craniana Posterior/patologia , Hidrocefalia/patologia , Hidrocefalia/cirurgia , Ventriculostomia/efeitos adversos , Adulto , Idoso , Feminino , Humanos , Hidrocefalia/diagnóstico por imagem , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Risco , Adulto Jovem
9.
Clin Pract Cases Emerg Med ; 1(2): 132-135, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-29849421

RESUMO

Subarachnoid hemorrhage (SAH) may present with cardiac arrest (SAH-CA). We report a case of SAH-CA to assist providers in distinguishing SAH as an etiology of cardiac arrest despite electrocardiogram findings that may be suggestive of a cardiac etiology. SAH-CA is associated with high rates of return of spontaneous circulation, but overall poor outcome. An initially non-shockable cardiac rhythm and the absence of brain stem reflexes are important clues in indentifying SAH-CA.

10.
Neurocrit Care ; 26(1): 96-102, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27389006

RESUMO

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.


Assuntos
Competência Clínica , Cuidados Críticos/métodos , Internato e Residência/métodos , Neurologia/educação , Treinamento por Simulação/métodos , Bolsas de Estudo , Humanos
11.
Pract Neurol ; 17(1): 39-41, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27671993

RESUMO

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.


Assuntos
Infecções por Escherichia coli/diagnóstico , Doenças Transmitidas por Alimentos/diagnóstico , Síndrome Hemolítico-Urêmica/diagnóstico , Carne/microbiologia , Convulsões/diagnóstico , Estupor/diagnóstico , Animais , Escherichia coli/isolamento & purificação , Infecções por Escherichia coli/complicações , Infecções por Escherichia coli/terapia , Feminino , Doenças Transmitidas por Alimentos/etiologia , Doenças Transmitidas por Alimentos/terapia , Síndrome Hemolítico-Urêmica/etiologia , Síndrome Hemolítico-Urêmica/terapia , Humanos , Carne/efeitos adversos , Pessoa de Meia-Idade , Convulsões/etiologia , Convulsões/terapia , Toxina Shiga/isolamento & purificação , Estupor/etiologia , Estupor/terapia , Suínos
13.
Neurocrit Care ; 26(2): 280-283, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-27624215

RESUMO

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.


Assuntos
Epilepsias Mioclônicas/etiologia , Parada Cardíaca/complicações , Transtornos Relacionados ao Uso de Substâncias/complicações , Adulto , Parada Cardíaca/etiologia , Humanos , Masculino , Adulto Jovem
14.
JAMA Neurol ; 73(5): 585-90, 2016 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-26975002

RESUMO

IMPORTANCE: The implications of stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs) sometimes found on prolonged electroencephalographic (EEG) recordings are uncertain. OBJECTIVE: To evaluate the incidence of SIRPIDs and their clinical implications in critically ill patients. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, international retrospective study was performed from October 1, 2012, through September 30, 2014, of consecutive adult patients hospitalized in intensive care units with alteration of consciousness who underwent EEG recordings at 3 separate centers. Demographic data, including admission diagnosis, age, sex, history of epilepsy, and EEG findings, were noted. Characteristics of SIRPIDs were documented. Data were evaluated for predictors of SIRPIDs and in-hospital mortality. Data analysis was performed from January 16, 2015, to June 15, 2015. MAIN OUTCOMES AND MEASURES: Incidence of SIRPIDs, association of SIRPIDs with mortality and other EEG characteristics, and EEG and clinical predictors of mortality. RESULTS: A total of 416 patients were studied. The median age of patients was 60 years (interquartile range, 46-71 years), and 252 (60.6%) were male. A total of 104 patients (25.0%) did not survive to hospital discharge. SIRPIDs were identified in 43 patients (10.3%). The proportion of patients with SIRPIDs was not significantly different across the 3 sites (P = .34). Anoxic brain injury (odds ratio [OR], 3.80; 95% CI, 1.73-8.33; P < .001), the use of antiepileptic medications (OR, 3.24; 95% CI, 1.31-8.00; P = .01), electrographic seizures (OR, 2.85; 95% CI, 1.13-7.19; P = .03), generalized periodic discharges with triphasic morphologic features (OR, 3.66; 95% CI, 1.67-8.02; P = .001), and sporadic sharp waves and periodic discharges (OR, 2.59; 95% CI, 1.13-5.92; P = .02) were independently associated with the presence of SIRPIDs. Older age (OR, 1.02; 95% CI, 1.01-1.04; P = .005), anoxic brain injury (OR, 3.49; 95% CI, 1.96-6.21; P ≤ .001), and absence of EEG reactivity (OR, 8.14; 95% CI, 4.20-15.79; P < .001) but not SIRPIDs (OR, 1.73; 95% CI, 0.79-3.78; P = .17) were independently associated with in-hospital mortality. CONCLUSIONS AND RELEVANCE: In critically ill patients undergoing EEG recordings, SIRPIDs occurred in 43 (10.3%) and were associated with other electrographic abnormalities previously reported to indicate poor prognosis. However, SIRPIDs were not independently associated with in-hospital mortality.


Assuntos
Cuidados Críticos , Estado Terminal , Epilepsia/diagnóstico , Epilepsia/fisiopatologia , Periodicidade , Adulto , Idoso , Eletroencefalografia , Feminino , Humanos , Cooperação Internacional , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estatísticas não Paramétricas
15.
Curr Treat Options Neurol ; 17(7): 358, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26002351

RESUMO

OPINION STATEMENT: Arteriovenous malformations (AVMs) pose a risk of morbidity and mortality throughout an affected patient's lifetime. Over the course of a patient's life, the risk of hemorrhage is approximately 1-4 % per year, and after an initial hemorrhage occurs, this risk may be higher. Other causes of morbidity include seizures, headaches, or progressive neurologic deficits. Once an AVM has been discovered, the utility of attempted obliteration or surgical resection compared to the risk of intervention should be entertained. The characteristics of the malformation as well as the patient's overall health status contribute to the decision to intervene on these lesions. For small lesions located in superficial areas without high-risk surgical characteristics (low-grade Spetzler-Martin grades), it is reasonable to consider surgical resection. In lesions that pose high-risk of complications from surgical removal, intra-arterial embolization, radiosurgery, or a combination of the two may be reasonable treatment options. Some AVMs at traditional high surgical risk may be amenable to partial embolization, allowing initially high-risk lesions to become better candidates for surgical resection. In some patients, particularly those who are older or who have multiple medical comorbidities, the risk of intervention as compared to the annual hemorrhage risk may warrant conservative management as opposed to intervention. The overall treatment strategy must be based on patient and AVM characteristics and careful risk-benefit ratio analysis.

16.
J Stroke Cerebrovasc Dis ; 24(3): 699-703, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25601179

RESUMO

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.


Assuntos
Angiopatia Amiloide Cerebral/complicações , Hemorragia Cerebral/etiologia , Fibrinolíticos/efeitos adversos , Hipertensão/complicações , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Angiopatia Amiloide Cerebral/diagnóstico , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/diagnóstico , Feminino , Humanos , Hipertensão/diagnóstico , Masculino , Pessoa de Meia-Idade , Minnesota , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Centros de Atenção Terciária , Adulto Jovem
18.
J Clin Neurosci ; 21(4): 692-4, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24100110

RESUMO

Rathke's cleft cysts (RCC) are usually benign, sellar and/or suprasellar lesions originating from the remnants of Rathke's pouch. Rarely, RCC can present with chemical meningitis, sellar abscess, lymphocytic hypophysitis, or intracystic hemorrhage. We describe an unusual presentation of RCC in which the patient presented with a clinical picture of chemical meningitis consisting of meningeal irritation, inflammatory cerebrospinal fluid profile, and enhancing pituitary and hypothalamic lesions, in addition to involvement of the optic tracts and optic nerve.


Assuntos
Cistos do Sistema Nervoso Central/patologia , Meningite/patologia , Cistos do Sistema Nervoso Central/diagnóstico , Cistos do Sistema Nervoso Central/cirurgia , Diagnóstico Diferencial , Humanos , Imagem por Ressonância Magnética , Masculino , Meningite/diagnóstico , Meningite/cirurgia , Pessoa de Meia-Idade , Resultado do Tratamento
20.
Neurology ; 81(20): 1796-8, 2013 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-24132378

RESUMO

A 59-year-old man had a 2-month history of nonfluctuating encephalopathy. He initially presented acutely with fevers, headaches, and word-finding difficulties. The sedimentation rate was elevated with a bland CSF and normal MRI head. Body CT showed diffuse pulmonary interstitial thickening with patchy opacification. Following treatment for pneumonia, there was resolution of fevers. No infectious etiology was identified. Within days of discharge, he developed bilateral uveitis, which was successfully treated with corticosteroid eyedrops and oral acyclovir. One month later, he developed confusion and unsteadiness. Repeat MRI was reportedly normal; body CT showed resolution of lung changes but diffuse lymphadenopathy persisted. A lymph node biopsy, reviewed at our institution, showed nonspecific reactive changes and fibrosis. Due to progressive encephalopathy and worsening headaches 2 months after symptom onset, the patient presented to our institution. On examination, he scored 30/38 on the Kokmen short test of mental status,(1) losing points for attention and immediate and delayed recall. Funduscopy revealed bilateral disc edema. He had mild appendicular ataxia and impaired tandem walk. The remainder of the examination was normal.


Assuntos
Peptídeos beta-Amiloides/metabolismo , Meningite/complicações , Uveíte/complicações , Vasculite/complicações , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Retina/patologia , Tomografia Computadorizada por Raios X , Vasculite/líquido cefalorraquidiano
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