Rates and Trends of Endotracheal Intubation in Patients With Status Epilepticus.

OBJECTIVE: Among patients with status epilepticus, we sought to determine the rate of endotracheal intubation, identify the physician specialties responsible for endotracheal intubation, and characterize the trend in use of endotracheal intubation over the last 20 years. METHODS: We performed a cross-sectional study using data from 2 sources. First, we used inpatient claims between 2009 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. Patients with status epilepticus were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, and those who underwent endotracheal intubation were identified based on Current Procedural Terminology codes. Medical specialties of providers performing intubation were identified based on Healthcare Provider Taxonomy Codes. Second, we used claims data from the National Inpatient Sample (NIS) to estimate the annual rates and trends of endotracheal intubation and tracheostomy among patients with status epilepticus from 1995 to 2014. RESULTS: Among 1971 Medicare beneficiaries with status epilepticus, 566 (29%) patients underwent endotracheal intubation. 375 (66%) patients were intubated on admission. The most common medical providers performing intubation in patients with status epilepticus were emergency medicine physicians (50.4%), anesthesiologists (16.4%), and pulmonary medicine physicians (10.1%). Neurologists accounted for 1.7% of all intubations. Among individuals with status epilepticus identified in the NIS, 248 681 (41.7%) were intubated. The proportion of patients intubated increased from 29.5% (95% confidence interval [CI]: 27.8%-31.3%, P = .018) in 1995 to 50.8% (95% CI: 49.6%-52%, P = .012) in 2014. The proportion of patients with status epilepticus who underwent tracheostomy increased from 2.2% (95% CI: 1.7%-2.7%, P = .005) in 1995 to 3.4% (95% CI: 3%-3.9%, P = .004) in 2014. SIGNIFICANCE: Approximately 1 in 3 patients with status epilepticus undergo endotracheal intubation. Over the last 20 years, the proportion of patients with status epilepticus undergoing endotracheal intubation has almost doubled. Neurologists perform a small percentage of these intubations.

A troponin study on patients with ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage: Type II myocardial infarction is significantly associated with stroke severity, discharge disposition and mortality.

Troponin elevations due to Type II myocardial infarction (T2MI) are associated with hemorrhagic and ischemic strokes but there is little data on stroke severity, troponin elevation and outcome. We studied 1655 patients from a tertiary medical center between 1/2013-4/2015 using multivariate regression analysis for demographics, vascular risk factors, admission stroke severity, laboratory tests, echocardiogram results and discharge disposition. Troponin levels were classified as normal <0.04 ng/ml and high >0.04 ng/ml (critical if >0.5 ng/ml). A T2MI was diagnosed by a trending troponin elevation; patients with type I MI, patients with subdural and epidural hematoma, or hemorrhagic metastatic disease and patients younger than 18 years old were excluded. We had 818 patients with ischemic stroke, 306 with intracerebral hemorrhage (ICH) and 169 with subarachnoid hemorrhage (SAH). Troponin was elevated (>0.04 ng/ml) in 24.1% of ischemic stroke patients, 27.1% in the ICH group, and in 39% of SAH patients. High initial and peak troponin levels were associated with higher National Institutes of Health Stroke Scale (NIHSS) in patients with ischemic stroke (OR 1.04; CI 95%, 1.02-1.07, p = .001) and (OR 1.05; CI 95%, 1.03-1.07, p < .001). In ICH patients, higher initial and peak troponin levels were not associated with worse ICH scores (OR 1.21; CI 95%, 0.66-2.22, p = .53) and (OR 1.36; CI 95%, 0.77-2.41, p = .29). In SAH patients, higher initial and peak troponin levels was associated with higher Hunt and Hess scores (OR 4.2; CI 95%, 1.6-11.4, p = .005) and (OR 3.14; CI 95%, 1.5-6.5, p = .002). In patients with high troponin levels mortality was 14.7% in ischemic stroke patients, 31.3% in our ICH patients, and 43.8% in our SAH. After adjusting for demographics and clinical risk factors, only high troponin ischemic stroke patients were associated with higher mortality (OR 6.16; CI95%, 2.46-15.4, p < .001), and worse discharge disposition (OR 2.3; CI 95%, 1.19-4.45, p = .01). High troponin levels were not associated with change of outcomes in patients with SAH and ICH after adjusting for demographics and clinical risk factors. Elevated troponin due to T2MI is common in patients with ischemic strokes, ICH, and SAH. It is significantly associated with stroke severity, poor discharge disposition, and high mortality. Troponin levels should be considered on admission for acute strokes.

Recurrent focal seizures as a feature of status epilepticus presenting as a peri-ictal water drinking.

We report a case of focal status epilepticus (SE) associated with peri-ictal water drinking (PIWD) behavior in a nine-year-old left-handed boy with epilepsy. We reviewed prior cases of epileptic peri-ictal water drinking. Only one adult patient with status epilepticus and PIWD has been reported previously. This is the first reported case of PIWD SE in a pediatric patient with frontal lobe epilepsy. We found PIWD to have no lateralizing value.

Risk of seizures and status epilepticus in older patients with liver disease.

OBJECTIVE: Seizures can be provoked by systemic diseases associated with metabolic derangements, but the association between liver disease and seizures remains unclear. METHODS: We performed a retrospective cohort study using inpatient and outpatient claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. The primary exposure variable was cirrhosis, and the secondary exposure was mild, noncirrhotic liver disease. The primary outcome was seizure, and the secondary outcome was status epilepticus. Diagnoses were ascertained using validated International Classification of Diseases, Ninth Edition, Clinical Modification codes. Survival statistics were used to calculate incidence rates, and Cox proportional hazards models were used to examine the association between exposures and outcomes while adjusting for seizure risk factors. RESULTS: Among 1 782 402 beneficiaries, we identified 10 393 (0.6%) beneficiaries with cirrhosis and 19 557 (1.1%) with mild, noncirrhotic liver disease. Individuals with liver disease were older and had more seizure risk factors than those without liver disease. Over 4.6 ± 2.2 years of follow-up, 49 843 (2.8%) individuals were diagnosed with seizures and 25 patients (0.001%) were diagnosed with status epilepticus. Cirrhosis was not associated with seizures (hazard ratio [HR] = 1.1, 95% confidence interval [CI] = 1.0-1.3), but there was an association with status epilepticus (HR = 1.9, 95% CI = 1.3-2.8). Mild liver disease was not associated with a higher risk of seizures (HR = 0.8, 95% CI = 0.6-0.9) or status epilepticus (HR = 1.1, 95% CI = 0.7-1.5). SIGNIFICANCE: In a large, population-based cohort, we found an association between cirrhosis and status epilepticus, but no overall association between liver disease and seizures.

Generalized Periodic Discharges With and Without Triphasic Morphology.

PURPOSE: Generalized periodic discharges (GPDs) with a triphasic morphology have been associated with nonepileptic encephalopathies. We conducted the study to assess the reliability in which electroencephalographers can differentiate triphasic from nontriphasic periodic discharges and to evaluate for the presence of electroencephalogram and clinical characteristics that are associated with a higher risk of seizures. METHODS: We studied prospectively 92 patients between May 2016 and February 2017. Each pattern was analyzed by two readers, who were blinded to clinical data. RESULTS: The interrater agreement was "substantial" (Kappa 0.67). The following features significantly increased the risk of developing seizures: the absence of triphasic morphology, focality on electroencephalogram, interburst suppression, a history of epilepsy, and an abnormal scan. The "GPD score" includes a history of epilepsy, focality on electroencephalogram, and the absence of triphasic morphology. A GPD score of 0 has 13% risk of seizures, whereas a score of 5 to 6 has a 94% risk. CONCLUSIONS: Triphasic morphology GPDs confer less risk of seizures when compared with patients with GPDs without triphasic morphology. Features with a higher risk of seizures include focality on electroencephalogram, interburst suppression, a history of epilepsy, and an abnormal scan. The GPD score can be used to assess the risk of developing seizures in patients with GPDs.

Acute Bilateral Ophthalmoplegia Due to Vertebrobasilar Dolichoectasia: A Report of Two Cases.

BACKGROUND Vertebrobasilar dolichoectasia (VBD) is a complex progressive arterial disease characterized by dilation, elongation, and tortuosity of the vertebral and basilar arteries, and may be congenital or acquired. VBD may lead to progressive compression of the brainstem, cranial nerve abnormalities, and intracranial hemorrhage, but may also be associated with arterial thrombosis, with ischemic stroke as the most common clinical outcome. CASE REPORT Two cases of VBD are presented, both with acute bilateral ophthalmoplegia and cranial nerve palsies, and vertebrobasilar arterial thrombosis that resulted in ischemic stroke. CONCLUSIONS VBD is a complex arterial disease with a variety of clinical manifestation, with bilateral ophthalmoplegia being a rare presentation. Clinical management of VBD is a challenge as there are no current management guidelines. Therefore, clinical management of cases of VBD should be individualized to balance the risks and benefits of treatment options for each patient.

Neuroscience step-down unit admission criteria for patients with intracerebral hemorrhage.

OBJECTIVES: The goal of our study is to determine optimal criteria which can be used to avoid admission to neuroscience intensive care units for patients with intracerebral hemorrhage (ICH). PATIENTS AND METHODS: This is a retrospective cohort study of 431 patients with primary ICH from January 2013 to the end of December 2015 and reviewed multiple admitting characteristics. Based on these needs, we tested the following step-down unit admission criteria: Supratentorial ICH, ICH volume <20 cc, no Intraventricular hemorrhage (IVH), systolic BP <200mmHg, no respiratory failure, GCS≥12. We classified 431 patients into two groups; 1-Patients who met step-down unit admission Criteria (71 patients). 2-Patients who didn't meet the criteria (360 patients). RESULTS: In our patients, 16.5% fulfilled the criteria. Length of stay in the ICU was 1.43days in step-down unit admission criteria patients. None of the patients who fulfilled the criteria were readmitted to the ICU, compared to 3 readmissions among the group of patients who did not fulfill the criteria (P=0.82). None of these patients required a neurosurgical procedure vs 47 patients (10.9%) in the other group (P=0.04). Among patients who met the criteria, 83.1% were discharged home or rehab RR 0.33 CI (0.19-0.55), (P<0.0001). CONCLUSION: We propose that patients who fulfill step-down unit admission criteria can be safely monitored in stroke unit and they have no need for ICU admission. Further studies are needed to validate these criteria in a prospective manner.

Spinal cord infarct caused from suspected fibrocartilaginous embolism.

INTRODUCTION: We report a case of spinal cord infarct as a result of suspected fibrocartilaginous embolism (FCE). CASE PRESENTATION: A 23-year-old man presented with sudden onset cervical and upper back pain followed by progressive weakness in his extremities after throwing a baseball. History, neurologic examination and spinal cord imaging were consistent with spinal cord infarct. We believe the cause was from FCE. DISCUSSION: Though rare, physicians should be familiar with this diagnosis and the proposed mechanisms. There is no specific treatment for FCE-related spinal cord infarct and long-term prognosis is largely dependent on the degree of spinal cord injury.

A Case of Neuro-Behcet's Disease Presenting with Central Neurogenic Hyperventilation.

BACKGROUND: Behcet's disease is a chronic inflammatory disorder usually characterized by the triad of oral ulcers, genital ulcers, and uveitis. Central to the pathogenesis of Behcet's disease is an autoimmune vasculitis. Neurological involvement, so called "Neuro-Behcet's disease", occurs in 10-20% of patients, usually from a meningoencephalitis or venous thrombosis. CASE REPORT: We report the case of a 46-year-old patient with Neuro-Behcet's disease who presented with central neurogenic hyperventilation as a result of brainstem involvement from venulitis. CONCLUSIONS: To the best of our knowledge, central neurogenic hyperventilation has not previously been described in a patient with Neuro-Behcet's disease.

Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: Institutional experience and literature review.

OBJECTIVES: To review the current practice in the diagnosis, monitoring and management of TCM in SAH patients at our tertiary referral institution and the relevant literature, and to evaluate the effect of certain treatment modalities on the outcome of those patients. PATIENTS AND METHODS: A retrospective institutional chart review of 800 patients with aneurysmal SAH from 2007 to 2014. Eighteen patients were identified to have both aneurysmal SAH and TCM based on echocardiogram. Demographic data, clinical parameters, radiographic findings, treatment modalities, and laboratory results were analyzed. RESULTS: The incidence of typical TCM in our patients was 2.2%. Mortality rate of TCM in SAH was 22% compared to the total mortality rate of all non-traumatic SAH patients of 15% in our institution over the same time period. Use of beta blockers prior to or after the diagnosis of TCM did not seem to affect their outcome. Majority of patients (61%) were on vasopressors prior to the diagnosis of TCM. Of those, 73% had good outcomes. Even after the diagnosis of TCM, good outcomes were observed in 6 of 7 patients who remained on vasopressors. CONCLUSION: Despite the general agreement on the importance of the avoidance of vasopressors in TCM, our experience showed that the use of vasopressors is safe in these patients. The use of beta blockers in our patients was not associated with significantly better outcomes despite multiple previous reports on beta blocker usage in TCM.

Ultrasound findings of carpal tunnel syndrome in a Hunter syndrome patient.

INTRODUCTION: Hunter syndrome (mucopolysaccharidosis II) is a rare genetic disorder. Carpal tunnel syndrome (CTS) is a common finding in these patients. METHODS: We report the ultrasound findings in a 40-year-old Hunter syndrome patient with severe CTS. RESULTS: Marked abnormalities of the median nerve were present proximal to the carpal tunnel with an unusual area of increased echogenicity between enlarged fascicles separating the area of maximal enlargement and the normal median nerve proximally. CONCLUSIONS: This case demonstrated unique ultrasound findings in a Hunter syndrome with CTS. Ultrasound also localized the median nerve lesion in the setting of end-stage median neuropathy and nonlocalizing electrophysiology.

Understanding Edward Muybridge: historical review of behavioral alterations after a 19th-century head injury and their multifactorial influence on human life and culture.

Edward Muybridge was an Anglo-American photographer, well known for his pioneering contributions in photography and his invention of the "zoopraxiscope," a forerunner of motion pictures. However, this 19th-century genius, with two original patents in photographic technology, made outstanding contributions in art and neurology alike, the latter being seldom acknowledged. A head injury that he sustained changed his behavior and artistic expression. The shift of his interests from animal motion photography to human locomotion and gait remains a pivotal milestone in our understanding of patterns in biomechanics and clinical neurology, while his own behavioral patterns, owing to an injury to the orbitofrontal cortex, remain a mystery even for cognitive neurologists. The behavioral changes he exhibited and the legal conundrum that followed, including a murder of which he was acquitted, all depict the complexities of his personality and impact of frontal lobe injuries. This article highlights the life journey of Muybridge, drawing parallels with Phineas Gage, whose penetrating head injury has been studied widely. The wide sojourn of Muybridge also illustrates the strong connections that he maintained with Stanford and Pennsylvania universities, which were later considered pinnacles of higher education on the two coasts of the United States.

A case of acute generalized exanthematous pustulosis associated with polyarteritis nodosa, responding to systemic steroids.

A patient with a known biopsy of polyarteritis nodosa diagnosis presented with cyclic fevers, acute kidney injury, and progression of rash from macular to pustular, worsening despite being on antibiotics, without evidence of infection on multiple cultures. The patient had a pathological diagnosis from a skin biopsy of acute generalized exanthematous pustulosis syndrome, with a total resolution of rash, fevers, and acute kidney injury on treatment with pulse steroids.