The Role of Routine Electroencephalography in the Diagnosis of Seizures in Medical Intensive Care Units.

Seizures should be diagnosed and treated to ensure optimal health outcomes in critically ill patients admitted in the medical intensive care unit (MICU). Continuous electroencephalography is still infrequently used in the MICU. We investigated the effectiveness of routine EEG (rEEG) in detecting seizures in the MICU. A total of 560 patients admitted to the MICU between October 2018 and March 2023 and who underwent rEEG were reviewed. Seizure-related rEEG constituted 47% of all rEEG studies. Totally, 39% of the patients experienced clinical seizures during hospitalization; among them, 48% experienced the seizure, and 13% experienced their first seizure after undergoing an rEEG study. Seventy-seven percent of the patients had unfavorable short-term outcomes. Patients with cardiovascular diseases were the most likely to have the suppression/burst suppression (SBS) EEG pattern and the highest mortality rate. The rhythmic and periodic patterns (RPPs) and electrographic seizure (ESz) EEG pattern were associated with seizures within 24 h after rEEG, which was also related to unfavorable outcomes. Significant predictors of death were age > 59 years, the male gender, the presence of cardiovascular disease, a Glasgow Coma Scale score ≤ 5, and the SBS EEG pattern, with a predictive performance of 0.737 for death. rEEG can help identify patients at higher risk of seizures. We recommend repeated rEEG in patients with ESz or RPP EEG patterns to enable a more effective monitoring of seizure activities.

Seasonal Variations in Stroke and a Comparison of the Predictors of Unfavorable Outcomes among Patients with Acute Ischemic Stroke and Cardioembolic Stroke.

We investigated the seasonal variations in stroke in 4040 retrospectively enrolled patients with acute ischemic stroke (AIS) admitted between January 2011 and December 2022, particularly those with cardioembolic (CE) stroke, and compared predictors of unfavorable outcomes between AIS patients and CE stroke patients. The classification of stroke subtypes was based on the Trial of ORG 10172 in Acute Stroke Treatment. Stroke occurrence was stratified by seasons and weekdays or holidays. Of all AIS cases, 18% were of CE stroke. Of all five ischemic stroke subtypes, CE stroke patients were the oldest; received the most thrombolysis and thrombectomy; had the highest initial National Institutes of Stroke Scale (NIHSS) and discharge modified Rankin Scale (mRS) scores; and had the highest rate of in-hospital complications, unfavorable outcomes (mRS > 2), and mortality. The highest CE stroke prevalence was noted in patients aged ≥ 85 years (30.9%); moreover, CE stroke prevalence increased from 14.9% in summer to 23.0% in winter. The main predictors of death in patients with CE stroke were age > 86 years, heart rate > 79 beats/min, initial NIHSS score > 16, neutrophil-to-lymphocyte ratio (NLR) > 6.4, glucose > 159 mg/dL, cancer history, in-hospital complications, and neurological deterioration (ND). The three most dominant factors influencing death, noted in not only patients with AIS but also those with CE stroke, are high initial NIHSS score, ND, and high NLR. We selected the most significant factors to establish nomograms for predicting fatal outcomes. Effective heart rhythm monitoring, particularly in older patients and during winter, may help develop stroke prevention strategies and facilitate early AF detection.

J-Shaped Relationship of Serum Uric Acid with Unfavorable Short-Term Outcomes among Patients with Acute Ischemic Stroke.

(1) Background: The role of uric acid in stroke outcomes remains inconclusive. (2) Methods: We retrospectively enrolled 3370 patients with acute ischemic stroke. (3) Results: Uric acid level was higher in men than in women. Univariate analyses revealed that the rates of hyperuricemia were higher in all patients and in women for unfavorable outcomes. For death, the hyperuricemia rates were higher in all patients including men and women, and the uric acid levels were also higher in all patients and in women. A J-shaped curve was observed between uric acid and the discharge-modified Rankin Scale score. Patients within Quartiles 1 (<4.1 mg/dL) and 4 (>6.5 mg/dL) of uric acid had higher rates of unfavorable outcomes and death than patients within Quartiles 2 (4.1−5.1 mg/dL) and 3 (5.1−6.2 mg/dL). Multivariable analyses for unfavorable outcomes revealed that Quartile 1 of uric acid was a significant factor in all patients and in men. In men, a significant factor for death was being in Quartile 1 of uric acid. In women, higher levels of uric acid or hyperuricemia (>6.6 mg/dL) were significant factors for death. (4) Conclusions: Lower uric acid levels are a predictor for unfavorable outcomes and death in men, and higher uric acid levels are a predictor for death in women.

Nomogram and Carotid Risk Score for Predicting Moderate or High Carotid Atherosclerosis among Asymptomatic Elderly Recycling Volunteers.

Carotid atherosclerosis is associated with cardiovascular and cerebrovascular events. We explored an appropriate method for selecting participants without ischemic cerebrovascular disease but with various comorbidities eligible for a carotid ultrasound. This was a retrospective subgroup analysis of the carotid plaque burden from a previous study involving a vascular and cognitive survey of 956 elderly recycling volunteers (778 women and 178 men; mean age: 70.8 years). We used carotid ultrasound to detect the carotid plaque and computed the carotid plaque score (CPS). A moderate or high degree of carotid atherosclerosis (MHCA) was defined as CPS > 5 and was observed in 22% of the participants. The CPS had positive linear correlations with age, systolic blood pressure, and fasting glucose. We stratified the participants into four age groups: 60−69, 70−74, 75−79, and ≥80 years. Multivariable analysis revealed that significant predictors for MHCA were age, male sex, hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, and a nonvegetarian diet. Coronary artery disease and advanced age were the two strongest predictors. We chose the aforementioned seven significant predictors to establish a nomogram for MHCA prediction. The area under the receiver operating characteristic curve in internal validation with 10-fold cross-validation and the classification accuracy of the nomogram were 0.785 and 0.797, respectively. We presumed people who have a ≥50% probability of MHCA warranted a carotid ultrasound. A flowchart table derived from the nomogram addressing the probabilities of all models of combinations of comorbidities was established to identify participants who had a probability of MHCA ≥ 50% (corresponding to a total nomogram score of ≥15 points). We further established a carotid risk score range from 0 to 17 comprising the seven predictors. A carotid risk score ≥ 7 was the most optimal cutoff value associated with a probability of MHCA ≥ 50%. Both total nomogram score ≥ 15 points and carotid risk score ≥ 7 can help in the rapid identification of individuals without stroke but who have a ≥50% probability of MHCA­these individuals should schedule a carotid ultrasound.

Status Epilepticus Related Takotsubo Syndrome - A Case Report.

PURPOSE: Takotsubo syndrome (TTS) is characterized angiographically by transient left ventricular systolic dysfunction sparing the basal segments of the left ventricle and absence of obstructive coronary artery disease. Epileptic seizures as triggering events for TTS are uncommon, having only been described in approximately 100 previous cases Case report: A 64-year-old woman with a history of recent stroke-related seizures was admitted for an acute onset of right hemiparesis with dull response. Neurological examination revealed a forced deviation of the eyeballs to the left side and quadriplegia. No large intracranial artery occlusion was disclosed through computed tomography angiography, but an acute infarction at the right corona radiata was identified through magnetic resonance imaging. Electroencephalography showed frequent spike-and-wave complexes over the right cerebral hemisphere indicating subtle status epilepticus. Her consciousness deteriorated to a stuporous state, and her eyeballs were forced deviated to the right side with persistent twitching of the right limbs 10 hours later. The convulsive status epilepticus (CSE) subsided after intravenous infusion of midazolam. However, atrial flutter with inverted T-wave and elevated high-sensitivity troponin I were observed 12 hours after CSE. Arrhythmia was soon alleviated through appropriate treatment. A further coronary angiography did not show significant coronary artery stenosis but indicated that the midsection and the apex of the left ventricle ballooned out during systole as the base contracted normally, indicating a Takotsubo syndrome. CONCLUSION: Physicians need to monitor unusual arrhythmias, particularly atrial and ventricular arrhythmias, for the possibility of TTS in patients with epileptic seizure.

Rapid Identification of Patients Eligible for Direct Emergent Computed Tomography Angiography during Acute Ischemic Stroke: The DARE-PACE Assessment.

BACKGROUND: We investigated the clinical signs to establish a method for rapid identification of patients with the National Institute of Health Stroke Scale (NIHSS) score ≥ 8 eligible for direct brain CTA study; Methods: We retrospectively enrolled 2895 in patients with acute ischemic stroke (AIS). Four items in the NIHSS were selected as the main clinical signs of stroke; Results: A total of 922 (31.8%) patients had an initial NIHSS score of ≥8. The average door-to-CT time and door-to-CTA time were 13.4 ± 1.8 and 75.5 ± 44.5 min, respectively. Among 658 patients who had the priority signs, namely dense hemiplegia (D), aphasia with right arm drop (AR), and eyeball forced deviation (E), 634 patients (96.4%) with an NIHSS score ≥ 8 were identified. By using a classification and regression tree analysis, 153 patients with an NIHSS ≥ 8 were identified among 175 patients (87.4%) who had the secondary signs, namely hemiparesis with limb falls (P), aphasia (A), drowsy or worse consciousness (C), and eyeball limitation (E). The sensitivity, specificity, and accuracy were 85.4%, 97.7%, and 95.3%, respectively. CONCLUSIONS: The DARE-PACE assessment involving a checkbox list provides excellent accuracy for rapid identification of AIS patients with an NIHSS score ≥ 8 for direct CTA study to reduce the time delay for endovascular thrombectomy.

Comparison of Clinical Features, Immune-Inflammatory Markers, and Outcomes Between Patients with Acute In-Hospital and Out-of-Hospital Ischemic Stroke.

PURPOSE: We investigated the differences of clinical features, four immune-inflammatory markers, namely neutrophil counts, platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio (NLR), and systemic immune-inflammation index (SII), as well as outcomes between patients with in-hospital ischemic stroke (IHIS) and out-of-hospital ischemic stroke (OHIS). PATIENTS AND METHODS: We retrospectively enrolled 72 patients with IHIS and 3330 patients with OHIS. RESULTS: IHIS accounted for 2% of all patients with ischemic stroke and occurred more often in cardiology and orthopedic surgery wards. Infection, cardiac disease, and pulmonary disorder were the most common causes of hospitalization. Compared with those with OHIS, patients with IHIS had higher levels of immune-inflammatory markers, initial National Institute of Health Stroke Scale (NIHSS) scores, longer hospital stays, higher rates of heart disease, large-artery atherosclerosis or cardioembolism, received more intravenous thrombolysis (IVT) or endovascular thrombectomies (EVTs), more complications, unfavorable outcomes, and mortality. Every immune-inflammatory marker exhibited positive correlations with initial NIHSS scores and discharge modified Rankin Scale scores among patients with OHIS. NLR and SII were higher among patients with a fatal outcome in both groups. Among patients receiving IVT, most of treatment time intervals were shorter for those with IHIS than those with OHIS. Significant factors for mortality were NLR >5.5, atrial fibrillation, and complications, with a C-statistic of 0.897 in those with IHIS; in those with OHIS, these factors were an initial NIHSS score of >10, NLR >6.0, atrial fibrillation, prior stroke, cancer history, and complications with a C-statistic of 0.902. The results were similar after replacing the NLR with SII. CONCLUSION: Patients with IHIS had more complicated clinical features, higher levels of immune-inflammatory markers, and higher rates of mortality than patients with OHIS. The most significant predictor for mortality among those with OHIS was NIHSS score >10, and the predictors among patients with IHIS were NLR >5.5 and SII >2120.

Acute and chronic bilateral internal carotid artery occlusion.

PURPOSE: Occlusion of both internal carotid arteries (ICAs) is rare. Clinical manifestations of stroke vary widely. We conducted a retrospective review to compare acute and chronic bilateral ICA occlusion. METHODS: We retrospectively reviewed records of inpatients with acute ischemic stroke and carotid duplex sonography (CDS) during the period from February 2006 to February 2021. RESULTS: Bilateral ICA occlusion and acute bilateral ICA occlusion accounted for 0.3% and less than 0.1% of all ischemic stroke cases, respectively. All five patients with acute bilateral ICA occlusion presented with consciousness disturbance. Three patients died within 1 week, and two patients had a vegetative outcome. Pituitary apoplexy with bilateral ICA occlusion was observed in one patient. Forward bilateral ophthalmic arterial flow (OAF) was detected in all three patients who received CDS. Among 13 patients with chronic bilateral ICA occlusion, five and six had modified Rankin Scale (mRS) scores upon discharge of more than 5 and less than 2, respectively; two patients did not have a stroke. Of the 13 patients, 11 had reversed bilateral OAF. Patients with acute bilateral ICA occlusion had a higher rate of initial consciousness disturbance, Glasgow Coma Scale score of less than 9, National Institute of Health Stroke Scale score of more than 20, and mRS score of more than 5. than that of patients with chronic bilateral ICA occlusion. CONCLUSION: Patients with acute bilateral ICA occlusion had higher initial stoke severity, poorer collateral circulation, and worse clinical outcomes than did those with chronic bilateral ICA occlusion. Physicians must pay attention to rare causes of acute bilateral ICA occlusion, including pituitary apoplexy.

Association of a High Neutrophil-to-Lymphocyte Ratio with Hyperdense Artery Sign and Unfavorable Short-Term Outcomes in Patients with Acute Ischemic Stroke.

PURPOSE: Immune-inflammatory processes are involved in all the stages of stroke. This study investigated the association of the neutrophil-to-lymphocyte ratio (NLR) with the hyperdense artery sign (HAS) observed on brain computed tomography (CT) and with clinical features in patients with acute ischemic stroke. METHODS: We retrospectively enrolled 2903 inpatients with acute ischemic stroke from May 2010 to May 2019. Data collected included imaging studies, risk factors, laboratory parameters, and clinical features during hospitalization. RESULTS: The HAS was identified in 6% of the 2903 patients and 66% of the 236 patients with acute middle cerebral artery occlusion. Patients with the HAS had a higher NLR. HAS prevalence was higher in men and patients with cardioembolism. The NLR exhibited positive linear correlations with age, glucose and creatinine levels, length of hospital stay, initial National Institutes of Health Stroke Scale (NIHSS) scores, and mRS scores at discharge. The NLR was significantly higher in patients with large-artery atherosclerosis and cardioembolism and was the highest in patients with other determined etiology. Multivariate analysis revealed that an initial NIHSS score of ≥10 and an NLR of >3.5 were significant positive factors, whereas diabetes mellitus and age > 72 years were significant negative factors for the HAS, with a predictive performance of 0.893. An initial NIHSS score of ≥5, positive HAS, age > 75 years, diabetes mellitus, an NLR of >3.5, female sex, a white blood cell count of >8 × 103/mL, and elevated troponin I were significant predictors of unfavorable outcomes, with a predictive performance of 0.886. CONCLUSION: An NLR of >3.5 enabled an efficient prediction of CT HAS. In addition to conventional risk factors and laboratory parameters, both an NLR of >3.5 and CT HAS enabled improved prediction of unfavorable stroke outcomes.

Impact of code stroke on thrombolytic therapy in patients with acute ischemic stroke at a secondary referral hospital in Taiwan.

BACKGROUND: Efficacy of thrombolytic therapy decreases with time elapsed from symptom onset. We sought to identify the impact of code stroke on the thrombolytic therapy. METHODS: Code stroke is activated by the emergency physician when a patient is eligible for thrombolytic therapy. We retrospectively reviewed patients with acute ischemic stroke between January 2011 and December 2014. RESULTS: In total, 1809 patients were enrolled. Code stroke was activated in 233 of 351 patients arriving at the emergency room (ER) within 3 h of symptom onset, and in 21 patients arriving >3 h. The sensitivity, specificity, and positive and negative predictive values of code stroke were 76%, 46%, 72%, and 51%, respectively. Thrombolytic therapy was provided to 58 patients, accounting for 3.4% of all cerebral infarcts. Code stroke was activated in 40 of these patients. The most common reasons for excluding thrombolytic therapy were: National Institute of Health Stroke Scale (NIHSS) < 6, intracranial hemorrhage (ICH), and age >80 years. Mean liaison-to-neurological evaluation time was only 6 min. Code stroke activation significantly reduced all the intervals, except for the onset-to-ER and door-to-order times. During the 4-year study period, there were significant reductions of the door-to-neurology liaison time by 28 min and door-to-laboratory time by 22 min. The proportion of door-to-needle time within 60 min improved from 33% in 2011 to 67% in 2014. Improved NIHSS scores during hospitalization were most prominent in tPA-treated patients. Symptomatic ICH occurred in 3.6% patients arriving within 3 h. Death occurred in 50% of patients received tPA treatment on family's request, and only 13% of those patients had favorable outcome. CONCLUSION: Code stroke is effective in reducing in-hospital delays. The accuracy of code stroke activation has acceptable sensitivity but low specificity. Rapid patient assessment by neurologists increases the number of patients eligible for thrombolytic therapy.

Vascular, Cognitive, and Psychomental Survey on Elderly Recycling Volunteers in Northern Taiwan.

Background: Stroke and dementia represent frequent causes of psychophysical and socioeconomic burdens. We conducted a vascular, cognitive, and psychomental survey involving elderly volunteers at community-based recycling stations in Northern Taiwan. Methods: Recycling volunteers aged ≥60 years were surveyed. We recorded seven parameters, namely (1) body mass index (BMI), (2) fasting glucose, (3) fasting cholesterol, (4) ankle-brachial index (ABI), (5) carotid duplex sonography, (6) five-item Brief Symptom Rating Scale (BSRS-5) score, and (7) eight-item Interview to Differentiate Aging and Dementia (AD8). During the carotid duplex study, we measured the carotid intima-media thickness (CIMT) and the carotid total plaque score (CTPS) of the common and internal carotid arteries. Results: In total, 985 subjects (mean age: 70.8 years) participated in this study. Among these, 81% were women, and 52% were vegetarians. The average ABI, CIMT, and CTPS were higher in men, whereas women had higher cholesterol levels and BSRS-5 scores. Obesity, hypertension, hyperglycemia, and hyperlipidemia were present in 21, 38, 9, and 27% of all subjects, respectively. Carotid plaques with mild (CTPS 1-5), moderate (CTPS 5.1-10), and severe (CTPS > 10) atherosclerosis were detected in 45, 16, and 7% of the subjects, respectively. Mild cognitive impairment (AD8 > 2) was observed in 13% of the subjects, whereas moderate mood disorder (BSRS-5≧10) was observed in only 1% of subjects. Vegetarians had a lower BMI, systolic blood pressure (SBP), cholesterol, CIMT, and CTPS than did non-vegetarians. Substantial predictors of severe atherosclerosis were advanced age (>70 years), male sex, history of heart disease, hyperlipidemia, and currently elevated SBP and cholesterol levels. Predictors of mild cognitive impairment were illiteracy, history of hypertension, hyperlipidemia, and moderate mood disorder. Conclusions: Subclinical carotid atherosclerosis was common in elderly recycling volunteers, with 23% having moderate to severe stenosis. Vegetarians had a reduced risk of atherosclerosis. The low incidence of moderate mood disorder might indicate that recycling work enhances psychomental health. In addition, a healthier lifestyle, better mood condition, and vegetarian diet might contribute to lower incidence of mild cognitive impairment.

Common Neurological Disorders Involving Inpatient Liaisons at a Secondary Referral Hospital in Taiwan: A Retrospective Cross-Sectional Study.

BACKGROUND AND PURPOSE: The requirement for neurology liaison is increasing in accordance with the growing health care demands associated with aging populations. The aim of this study was to characterize the nature of neurological inpatient liaisons (NILs) to help plan for the appropriate use of neurology resources. METHODS: This was a retrospective cross-sectional study of NILs in a secondary referral hospital over a 12-month period. RESULTS: There were 853 neurological consultations with a liaison rate of 3% per admission case. Chest medicine, gastroenterology, and infectious disease were the three most frequent specialties requesting liaison, and altered consciousness, seizure, and stroke were the three most frequent disorders for which a NIL was requested. Infection was the most common cause of altered consciousness. Epilepsy, infection, and previous stroke were common causes of seizure disorders. Acute stroke accounted for 44% of all stroke disorders. Electroencephalography was the most recommended study, and was also the most frequently performed. Ninety-five percent of emergency consultations were completed within 2 hours, and 85% of regular consultations were completed within 24 hours. The consult-to-visit times for emergency and regular consultations were 44±47 minutes (mean±standard deviation) and 730±768 minutes, respectively, and were shorter for regular consultations at intensive care units (p=0.0151) and for seizure and stroke disorders (p=0.0032). CONCLUSIONS: Altered consciousness, seizure, and stroke were the most common reasons for NILs. Half of the patients had acute neurological diseases warranting immediate diagnosis and treatment by the consulting neurologists. Balancing increasing neurologist workloads and appropriate health-care resources remains a challenge.

Massive Epistaxis from Internal Carotid Pseudoaneurysm during Acute Ischemic Stroke in a Patient with Nasopharyngeal Carcinoma.

PURPOSE: Carotid blowout syndrome due to rupture of internal carotid artery pseudoaneurysm in NPC patients with prior neck radiation is an uncommon but life-threatening complication. Concomitant carotid stenosis with ischemic stroke and carotid rupture from pseudoaneurysm is rare. CASE REPORT: A 71-year-old man had a history of NPC treated with radiation therapy 26 years ago. He was admitted to the hospital because of minor ischemic stroke and tarry stool. The carotid duplex sonography disclosed severe stenotic lesion in the proximal right internal carotid artery. A subsequent recurrent stroke on day three associated with nasal cavity bleeding resulted in an endotracheal intubation. Another episodic of massive epistaxis occurred on day 10 caused hypovolemic shock. Pseudoaneurysm of the left internal carotid artery was found by emergent angiography and was immediately obliterated by endovascular treatment with microcoils and glue. CONCLUSION: Carotid blowout syndrome in NPC patients during acute ischemic stroke warrants further cervical angiographic study. Endovascular treatment provides immediate hemostasis and obliteration of ICA pseudoaneurysm.

Contact heat evoked potentials in normal subjects.

Laser-evoked potentials are widely used to investigate nociceptive pathways. The newly developed contact heat stimulator for evoking brain response has the advantages of obtaining reliable scalp potentials and absence of cutaneous lesions. This study aimed to identify the most appropriate stimulation site with consistent cortical responses, and to correlate several parameters of the contact heat evoked potentials (CHEPs) with age, gender, and body height in normal subjects. CHEPs were recorded at Cz with a contact heat stimulator (Medoc, Israel) in 35 normal controls. The subjects were asked to keep eyes open and remain alert. The baseline temperature was 32 degrees C, and stimulation peak heat intensity of 51 degrees C was applied to five body sites: bilateral forearm, right dorsum hand, right peroneal area, and right dorsum foot. Reproducible CHEPs were recorded more frequently when stimulated at volar forearm (62.5%) than at the lower limbs (around 40%). The first negative peak latency (N1) was 370.1 +/- 20.3 ms, first positive peak latency (P1) was 502.4 +/- 33.0 ms, and peak to peak amplitude was 10.2 +/- 4.9 microV with stimulation of the forearm. Perceived pain intensity was not correlated with the presence or amplitude of CHEPs. No gender or inter-side differences were observed for N1 latency and N1-P1 amplitude. Also, no correlation was noted between N1 and age or body height. These results support future clinical access of CHEPs as a diagnostic tool.