Pain Control and Sedation in Neuro Intensive Critical Unit

Neurocritical patients who can self-report pain use the 0-10 numerical rating scale (NRS, verbal or visual form). However, critically ill patients whose nervous systems cannot express pain use the behavioral pain scale (BPS) and the critical care pain observation tool (CPOT) behavioral pain assessment tools. These tools reveal pain-related changes in movement, facial expression, posture, and physiological indicators such as heart rate, blood pressure, and respiratory rate. In pain control, it is first essential to reduce unnecessary painkillers through non-drug therapy and maximize the effect of the administered analgesics. For nonneuropathic pain, narcotic analgesics such as fentanyl, hydromorphone, morphine, and remifentanil are administered intravenously. Gabapentin, pregabalin, and carbamazepine are recommended along with narcotic analgesics for neuropathic pain control. In addition, nonnarcotic analgesics for multi-modal analgesia are used to reduce the use of narcotic analgesics or the side effects of narcotic analgesics. In the intensive care unit (ICU), the sedation-agitation scale (SAS) and the Richmond agitation-sedation scale (RASS) are used to determine the depth of sedation to be maintained during shallow or deep sedation, considering the condition of the critically ill patient. When selecting sedatives for critically ill patients, preferentially consider nonbenzodiazepines such as propofol or dexmedetomidine rather than benzodiazepines such as midazolam or lorazepam. In addition, patients use painkillers or sedatives for over a week, and neurological changes or physiological dependence may occur. Therefore, clinicians should evaluate the critically ill patient’s condition, and sedatives and painkillers should be reduced or discontinued.

Cerebral Venous Thrombosis without Thrombocytopenia after COVID-19 Vaccination

Cerebral venous thrombosis (CVT) is a rare form of cerebrovascular attack and its predisposing factors commonly co-exist. In the coronavirus disease 2019 (COVID-19) era, various side effects of COVID-19 vaccine have been reported, and CVT is one of the well-known types. It is usually explained as prothrombotic immune thrombocytopenia by an antibody binding to platelet factor 4 receptor. However, some cases are irrelevant to thrombocytopenia and calls for a new explanation. Here we report a case of CVT without thrombocytopenia after COVID-19 vaccination.

Polyneuropathy Following Nitrous Oxide Abuse / 대한신경근육질환학회지

Nitrous oxide (N2O), an anesthetic gas, has been abused by some people for entertainment purposes. Recently, N2O (under the name of "Happy Balloon") abuse has become problematic among young people in Korea. N2O intoxication can develop a neuropathy, as well as other systemic disorders, either by inactivating vitamin B12 or by a direct neurotoxic mechanism. Here, we report a case of peripheral neuropathy with possible coexisting myelopathy following N2O abuse.

A Guillain-Barré Syndrome with Anti-GQ1b and Anti-GT1a Antibodies Positivity Manifesting with Acute Bulbar Palsy and Subsequent Delayed Ophthalmoplegia / 대한신경근육질환학회지

In Guillain-Barré syndrome (GBS) and its variant, anti-GQ1b antibody has a pathogenic role for ophthalmoplegia. In addition, anti-GT1a antibody is related with lower cranial nerve involvement. This report describes a 60-year-old male patient with GBS manifesting with initially isolated dysphagia and subsequently developed ophthalmoplegia. Both immunoglobulin G type anti-GQ1b and anti-GT1a antibodies were detected in the patient’s serum. A mechanism regarding subsequent involvement of respective cranial nerves remains to be elucidated.

A Guillain-Barré Syndrome with Anti-GQ1b and Anti-GT1a Antibodies Positivity Manifesting with Acute Bulbar Palsy and Subsequent Delayed Ophthalmoplegia / 대한신경근육질환학회지

In Guillain-Barré syndrome (GBS) and its variant, anti-GQ1b antibody has a pathogenic role for ophthalmoplegia. In addition, anti-GT1a antibody is related with lower cranial nerve involvement. This report describes a 60-year-old male patient with GBS manifesting with initially isolated dysphagia and subsequently developed ophthalmoplegia. Both immunoglobulin G type anti-GQ1b and anti-GT1a antibodies were detected in the patient’s serum. A mechanism regarding subsequent involvement of respective cranial nerves remains to be elucidated.

An Unusual Case of Benign Episodic Bilateral Mydriasis

PURPOSE: Although benign episodic mydriasis has been rarely reported worldwide, most of the reports so far have occurred in unilaterally. To report an unusual case of benign episodic bilateral mydriasis. CASE SUMMARY: Nineteen-year-old woman who presented with intermittent dilation of both pupils two months ago. She had difficulty on reading and doing tasks because of her visual blur. This symptom usually lasted for 1–2 hours, occurred once every 2–3 days, most frequently during stressful situations. Headaches and dizziness accompanied the eye symptoms, and her pupils were both 5 mm in a lighted room and both 7 mm in a dark room. All tests, including brain magnetic resonance imaging, showed no abnormal findings. We diagnosed her as benign episodic bilateral mydriasis. The frequency of her symptoms decreased during the university vacation period. CONCLUSIONS: In the absence of ophthalmologic or neurologic abnormalities other than headaches in patients with transient mydriasis, benign episodic mydriasis should be considered as a differential diagnosis. Although benign episodic bilateral mydriasis has a unilateral predominance, for the first time the authors report that benign episodic mydriasis may occur in both eyes during same episode.

Renal Cholesterol Embolism during Warfarin Treatment

Cholesterol embolization syndrome (CES) usually occurs after endovascular procedures, it may also occurs after using anticoagulants and thrombolytics. We report a case of 66-year-old man with sudden elevation of creatinine after using warfarin due to cortical infarction. Histologic examinations revealed a cholesterol cleft on the arcuate artery. We concluded it as warfarin induced atheroembolic renal disease. Careful observation of kidneys is necessary in the case of renal abnormalities after using anticoagulation, considering the possibility of cholesterol embolism due to anticoagulant therapy.

Acute Ischemic Stroke in Moyamoya Syndrome Associated with Thyrotoxicosis

BACKGROUND: A few cases of moyamoya syndrome associated with thyrotoxicosis have been reported. However, studies on the association of hyperthyroidism with moyamoya syndrome are insufficient. CASE REPORT: Here we report a case of hyperthyroidism associated with moyamoya syndrome in a 41-year-old woman with aphasia and right side weakness. Brain imaging revealed acute cerebral infarction of left middle cerebral artery territory and occlusion of bilateral distal internal carotid arteries. CONCLUSION: Antithyroid medication stabilized the patient's neurologic deterioration, suggesting that thyrotoxicosis could aggravate acute cerebral infarction caused by moyamoya syndrome.

Miliary Tuberculosis Mimicking Brain Metastasis from Renal Cell Carcinoma

BACKGROUND: Miliary tuberculosis (TB) can cause diagnostic confusion for clinicians because its radiological appearance can resemble that of metastatic cancer. CASE REPORT: Here, we describe the case of a 72-yearold woman with miliary TB mimicking brain metastasis from renal cell carcinoma. The patient visited our clinic because of dysarthria and sluggish speech. A metastatic cancer such as renal cell carcinoma or brain tumor was suspected. However, the patient was diagnosed with miliary TB associated with multiple intracranial tuberculomas and a subsequent paradoxical response to anti-TB therapy. CONCLUSION: Clinicians should be aware that miliary TB can mimic metastatic cancer even in older people, especially in TB-endemic regions.

Co-occurrence of Guillain-Barré Syndrome and Acute Disseminated Encephalomyelitis with Dual Positive of Anti-GT1a and Anti-GM1 Antibodies

Acute disseminated encephalomyelitis (ADEM) and Guillain-Barré syndrome (GBS) are both rare post-infectious neurological disorders. The co-existence of these conditions has often been reported despite of low incidence. We describe a 20-year-old male, who presented with acute flaccid paralysis and encephalopathy. The patient showed reversible MRI lesions suggesting ADEM. This case showed anti-GT1a IgG and anti-GM1 IgM antibodies positivity. We suggest that certain immunogenicity within central and peripheral nervous system may share a common autoimmune process during the disease course.

Normal Magnetic Resonance Perfusion Imaging and Atypical Posterior Reversible Encephalopathy Syndrome in Chronic Kidney Disease

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is classically characterized by symmetric vasogenic edema in the parietooccipital areas, but may occur at other sites with varying imaging appearances. CASE REPORT: A 55-year old female with chronic kidney disease (CKD) was admitted to the emergency room, presenting with nausea, vomiting and seizure. The initial blood pressure was 145/90 mmHg. Fluid attenuated inversion recovery demonstrated diffuse vasogenic edema in the bilateral cortical and subcortical white matters involving the frontal lobes. Perfusion magnetic resonance imaging (MRP) showed no hyper- or hypoperfusion at blood pressure levels of 140/50 mmHg. A follow-up magnetic resonance imaging at 3 weeks later demonstrated complete resolution of previous lesions. CONCLUSIONS: Earlier reports have demonstrated that PRES can occur in cases of atypical distributions, and features of imaging findings and normotensive settings. It is important to note that PRES is a dynamic process. As a result, we suggest that MRP must be considered in the appropriate temporal framework, to avoid misinterpretation of the other diseases, especially in CKD patients.

Perfusion-Weighted MRI Parameters for Prediction of Early Progressive Infarction in Middle Cerebral Artery Occlusion

OBJECTIVE: Early progressive infarction (EPI) is frequently observed and related to poor functional outcome in patients with middle cerebral artery (MCA) infarction caused by MCA occlusion. We evaluated the perfusion parameters of magnetic resonance imaging (MRI) as a predictor of EPI. METHODS: We retrospectively analyzed patients with acute MCA territory infarction caused by MCA occlusion. EPI was defined as a National Institutes of Health Stroke Scale increment ≥2 points during 24 hours despite receiving standard treatment. Regional parameter ratios, such as cerebral blood flow and volume (rCBV) ratio (ipsilateral value/contralateral value) on perfusion MRI were analyzed to investigate the association with EPI. RESULTS: Sixty-four patients were enrolled in total. EPI was present in 18 (28%) subjects and all EPI occurred within 3 days after hospitalization. Diabetes mellitus, rCBV ratio and regional time to peak (rTTP) ratio showed statically significant differences in both groups. Multi-variate analysis indicated that history of diabetes mellitus [odds ratio (OR), 6.13; 95% confidence interval (CI), 1.55-24.24] and a low rCBV ratio (rCBV, <0.85; OR, 6.57; 95% CI, 1.4-30.27) was significantly correlated with EPI. CONCLUSION: The incidence of EPI is considerable in patients with acute MCA territory infarction caused by MCA occlusion. We suggest that rCBV ratio is a useful neuro-imaging parameter to predict EPI.

Brain Oxygen Monitoring via Jugular Venous Oxygen Saturation in a Patient with Fulminant Hepatic Failure / 대한중환자의학회지

Fulminant hepatic failure (FHF) is often accompanied by a myriad of neurologic complications, which are associated with high morbidity and mortality. Although appropriate neuromonitoring is recommended for early diagnosis and to minimize secondary brain injury, individuals with FHF usually have a high chance of coagulopathy, which limits the ability to use invasive neuromonitoring. Jugular bulb venous oxygen saturation (JvO₂) monitoring is well known as a surrogate direct measures of global brain oxygen use. We report the case of a patient with increased intracranial pressure due to FHF, in which JvO₂ was used for appropriate brain oxygen monitoring.

Brain Oxygen Monitoring via Jugular Venous Oxygen Saturation in a Patient with Fulminant Hepatic Failure / 대한구급학회지

Fulminant hepatic failure (FHF) is often accompanied by a myriad of neurologic complications, which are associated with high morbidity and mortality. Although appropriate neuromonitoring is recommended for early diagnosis and to minimize secondary brain injury, individuals with FHF usually have a high chance of coagulopathy, which limits the ability to use invasive neuromonitoring. Jugular bulb venous oxygen saturation (JvO₂) monitoring is well known as a surrogate direct measures of global brain oxygen use. We report the case of a patient with increased intracranial pressure due to FHF, in which JvO₂ was used for appropriate brain oxygen monitoring.

Risk Factors for Peripheral Artery Disease in Patients With Ischemic Stroke or Transient Ischemic Attack

BACKGROUND: Co-morbid vascular disease, such as coronary artery disease or peripheral artery disease (PAD) is frequently combined in patients with ischemic stroke (IS) or transient ischemic attack (TIA). However, PAD has been underestimated and underevaluated in these patients. The aims of this study were to know the prevalence of PAD and to assess the risk factors for PAD in patients with IS or TIA. METHODS: Between February in 2006 and March in 2011, ankle-brachial index (ABI) was measured in 724 patients with acute IS or TIA. We compared the demographics and baseline characteristics, including risk factors and stroke subtypes between patients combined with and without PAD. RESULTS: PAD was found in 13.3% (96/724) and more frequent in patients with large artery disease. Patients with PAD were older (mean age 74.5+/-10.4 vs. 65.5+/-12.5, p<0.001),and had higher body mass index (BMI) (23.15+/-3.46 vs. 24.03+/-3.25; p=0.019), higher serum level of hemoglobin (12.99+/-2.12 vs. 13.68+/-1.87; p=0.001) and severe initial neurological deficit measured by National Institute of Health Stroke Scale (NIHSS) (median 4, IQR:2,7 vs. 2, IQR:1,5; p=0.001) on admission than those without PAD; patients with PAD were more likely to have hypertension (79.2% vs. 61.6%; p=0.001), diabetes (44.8% vs. 29.5%; p=0.004), and previous stroke or TIA (35.4% vs. 23.9%; p=0.022). In multivariable logistic regression analysis, age (OR, 1.069; 95% CI, 1.042-1.096; p<0.001) and diabetes (OR, 1.904; 95% CI, 1.134-3.196; p=0.015) were independently associated with PAD in IS or TIA. CONCLUSIONS: Age and diabetes were independent risk factors for PAD in IS or TIA.

Predictors of functional outcome of patients in neurological intensive care unit

Background: Little is known regarding the functional outcome and quality of life of neuro-ICU survivors. In Korea, the neuro-ICU concept was introduced relatively late and data about long term outcome and predictors concerning functional outcome is scarce. The main objective of this study was to analyze functional outcome and mortality, and to determine prognostic predictors for the outcome in patients admitted to Korean neuro-ICUs. Methods: Consecutive adult (≥ 15-years-of-age) patients admitted to a neuro-ICU due to various causes including ischemic or hemorrhagic stroke, and other neurological or neurosurgical problems such as traumatic brain injury, seizure, or drug intoxication during an 18-month period from July 2008 through December 2009 were included. Demographic and clinical variables were compared between groups stratifi ed based on 6-month modifi ed Rankin scale score. Results: Of 555 patients, there were signifi cant differences in age (P=0.013), sex (P=0.02), hospital stay (P<0.01), neuro-ICU stay (P<0.01), admission diagnosis (P=0.001), intubation (P<0.01), mechanical ventilation (P<0.01), tracheostomy (P<0.01), comorbid conditions such as atrial fi brillation (P<0.01), cardiac complication (P<0.01) and pulmonary complication (P<0.01), a high Therapeutic Intervention Scoring System (TISS-28) score (P<0.01), and a high Acute Physiology and chronic health evaluation (APACHE) II score (P<0.01) between favorable and unfavorable outcome groups. The overall mortality rate was 15.0% (n=83). In multivariable logistic regression analysis, age, sex, high TISS-28, high APACHE II score, intubation, and cardiac complication were independent predictors of unfavorable outcome. Conclusion: The identifi ed predictors for functional outcomes in Korean neuro-ICU patients will be an important aid in diagnosing and treating neuro-ICU patients.

Successful Treatment of Intractable Hiccup with Levetiracetam

Hiccups may be considered a form of myoclonus of diaphragm. Valproic acid has been considered the drug of choice in treatment of intractable hiccups; however, its various adverse events limit its use in the clinical basis, especially in elderly or complicated patients. Levetiracetam was known as a safe antiepileptic drug. However, the anti-hiccup property of the levetiracetam has been rarely reported. We report a 69-year old male patient who developed sudden persistent hiccups and was successfully treated with levetiracetam. Levetiracetam should be considered as alternative treatment option in selected patients with intractable hiccups.

Successful Treatment of Intractable Hiccup with Levetiracetam / 대한간질학회지

Hiccups may be considered a form of myoclonus of diaphragm. Valproic acid has been considered the drug of choice in treatment of intractable hiccups; however, its various adverse events limit its use in the clinical basis, especially in elderly or complicated patients. Levetiracetam was known as a safe antiepileptic drug. However, the anti-hiccup property of the levetiracetam has been rarely reported. We report a 69-year old male patient who developed sudden persistent hiccups and was successfully treated with levetiracetam. Levetiracetam should be considered as alternative treatment option in selected patients with intractable hiccups.

The Factors Associated with the Decision of r-tPA Use in Acute Ischemic Stroke Patients Aged 80 Years or Older / 대한뇌졸중학회지

BACKGROUND: Small proportions of all the elderly stroke patients receive recombinant tissue plasminogen activator (r-tPA) therapy, although old age is not a proven contraindication to intravenous thrombolytic therapy for acute ischemic stroke. The purpose of this study was to identify reasons for exclusion from r-tPA therapy and factors associated with the decision of r-tPA use in elderly patients with acute ischemic stroke. METHODS: From the acute stroke registries of 22 domestic university hospitals taking the r-tPA therapy from January 2007 to May 2010, we extracted data of all acute ischemic stroke patients who were aged 80 or over and arrived within onset 3 hours. For all patients, we assessed the eligibility of r-tPA therapy using National Institute of Neurological Disorders and Stroke (NINDS) r-tPA trial criteria. For eligible patients, we compared all clinical variables between patients who were treated with r-tPA and those who were not, and analyzed potential factors related to the decision of r-tPA use. RESULTS: A total of 494 patients were included in this study. 255 patients (51.6%) were excluded by NINDS r-tPA trial criteria and the major reasons for exclusion were minor neurological deficit (53.7%) and clinical improvement (17.3%). Among 239 patients who were eligible for r-tPA, 162 (32.8%) patients received r-tPA and 77 (15.6%) did not. Multivariable analysis showed that younger age, shorter time-delay from onset to admission, non-smoker, no history of prior stroke, good pre-stroke functional status and severe initial neurological deficit were independently associated with the decision of r-tPA use in the elderly stroke patients predictors for r-tPA treatment. CONCLUSION: In very elderly patients, mild neurological deficit on arrival and rapid clinical improvement in neurological symptoms were the main reasons for exclusion from thrombolytic therapy.