Noninvasive neuromonitoring with rheoencephalography: a case report.

Cerebral blood flow (CBF) autoregulation (AR) can be monitored using invasive modalities, such as intracranial pressure (ICP) and arterial blood pressure (ABP) to calculate the CBF AR index (PRx). Monitoring PRx can reduce the extent of secondary brain damage in patients. Rheoencephalography (REG) is an FDA-approved non-invasive method to measure CBF. REGx, a CBF AR index, is calculated from REG and arm bioimpedance pulse waves. Our goal was to test REG for neuromonitoring. 28 measurement sessions were performed on 13 neurocritical care patients. REG/arm bioimpedance waveforms were recorded on a laptop using a bioimpedance amplifier and custom-built software. The same program was used for offline data processing. Case #1: The patient's mean REGx increased from - 0.08 on the first day to 0.44 on the second day, indicating worsening intracranial compliance (ICC) (P < 0.0001, CI 0.46-0.58). Glasgow Coma Scale (GCS) was 5 on both days. Case #2: REGx decreased from 0.32 on the first recording to 0.07 on the last (P = 0.0003, CI - 0.38 to - 0.12). GCS was 7 and 14, respectively. Case #3: Within a 36-minute recording, REGx decreased from 0.56 to - 0.37 (P < 0.0001, 95%, CI - 1.10 to - 0.76). Central venous pressure changed from 14 to 9 mmHg. REG pulse wave morphology changed from poor ICC to good ICC morphology. Bioimpedance recording made it possible to quantify the active/passive status of CBF AR, indicate the worsening of ICC, and present it in real time. REGx can be a suitable, non-invasive alternative to PRx for use in head-injured patients.

Sustained Low-Efficiency Dialysis is Associated with Worsening Cerebral Edema and Outcomes in Intracerebral Hemorrhage.

BACKGROUND/OBJECTIVES: We postulated that renal replacement therapy (RRT) in ICH patients with advanced chronic kidney disease (CKD) is associated with increased frequency and size of perihematomal edema (PHE) expansion and worse patient outcomes. METHODS: The Get With the Guidelines-Stroke Registry was queried for all patients admitted with ICH (N = 1089). Secondary causes, brainstem ICH, and initial HV < 7 cc were excluded. We identified patients with advanced CKD with and without RRT following admission for ICH. ABC/2 formula was used to measure hematoma volume (HV) and PHE. Patient outcomes were 30-day mortality, 90-day modified Rankin Scale score, and discharge disposition. We used propensity scores and optimal matching to adjust for multiple covariates. RESULTS: At 48 h post-ICH, PHE expansion was a significant predictor of poor patient outcomes in our cohort. Patients with CKD who received sustained low-efficacy dialysis (SLED) treatment had larger 48 h PHE growth compared to both untreated CKD group (average treatment effect (ATE), 11.5; 95% CI, 4.9-18.1; p < 0.01) and all untreated patients (ATE, 7.43; 95% CI, 4.7-10.2; p < 0.01). Moreover, patients with RRT had significantly worse functional and mortality outcomes. CONCLUSIONS: SLED treatment in ICH patients with CKD was associated with significant increase in rate and frequency of PHE expansion. Absolute increase in PHE during 48-h post-ICH was associated with increased mortality and worse functional outcomes. Further prospective and multicenter evaluation is needed to differentiate the effects of RRT on hematoma dynamics and patient outcomes from those attributed to CKD.

Treatment of Anti-GAD65 Autoimmune Encephalitis With Methylprednisolone.

Background: Anti-glutamic acid decarboxylase 65 (anti-GAD65) antibody encephalitis is a rare form of autoimmune encephalitis that can lead to severe neurologic impairment, coma, and death. Case Report: We present the case of a 54-year-old male with severely altered mental status and profound neurologic impairment who rapidly progressed to a comatose state. Because of the patient's rapidly deteriorating status, lack of yield with diagnostic testing, and lack of clinical improvement with broad empiric treatments, the clinical decision was made to treat the patient with high-dose methylprednisolone, and the treatment returned the patient to his baseline mental status. After the patient's discharge, the autoimmune encephalitis panel returned positive for anti-GAD65 antibodies. Conclusion: This case illustrates the importance of considering a diagnosis of autoimmune encephalitis for patients with rapidly deteriorating mental status. Unless contraindicated, treatment with high-dose glucocorticoids can be successful for these patients. This case also shows a potential association between hypothyroidism and anti-GAD65 antibodies.

Periodic Lateralized Epileptiform Discharges can Survive Anesthesia and Result in Asymmetric Drug-induced Burst Suppression.

Drug-induced burst suppression (DIBS) is bihemispheric and bisymmetric in adults and older children. However, asymmetric DIBS may occur if a pathological process is affecting one hemisphere only or both hemispheres disproportionately. The usual suspect is a destructive lesion; an irritative or epileptogenic lesion is usually not invoked to explain DIBS asymmetry. We report the case of a 66-year-old woman with new-onset seizures who was found to have a hemorrhagic cavernoma and periodic lateralized epileptiform discharges (PLEDs) in the right temporal region. After levetiracetam and before anesthetic antiepileptic drugs (AEDs) were administered, the electroencephalogram (EEG) showed continuous PLEDs over the right hemisphere with maximum voltage in the posterior temporal region. Focal electrographic seizures also occurred occasionally in the same location. Propofol resulted in bihemispheric, but not in bisymmetric, DIBS. Remnants or fragments of PLEDs that survived anesthesia increased the amplitude and complexity of the bursts in the right hemisphere leading to asymmetric DIBS. Phenytoin, lacosamide, ketamine, midazolam, and topiramate were administered at various times in the course of EEG monitoring, resulting in suppression of seizures but not of PLEDs. Ketamine and midazolam reduced the rate, amplitude, and complexity of PLEDs but only after producing substantial attenuation of all burst components. When all anesthetics were discontinued, the EEG reverted to the original preanesthesia pattern with continuous non-fragmented PLEDs. The fact that PLEDs can survive anesthesia and affect DIBS symmetry is a testament to the robustness of the neurodynamic processes underlying PLEDs.