Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism.

PURPOSE: Catheter-directed thrombolysis (CDT) is a relatively new therapy for pulmonary embolism that achieves the superior clot resolution compared to systemic thrombolysis while avoiding the high bleeding risk intrinsically associated with that therapy. In order to examine the efficacy and safety of CDT, we conducted a retrospective cohort study of patients undergoing ultrasound-assisted CDT at our institution. METHODS: The charts of 30 consecutive patients who underwent CDT as a treatment of pulmonary embolism at our institution were reviewed. Risk factors for bleeding during thrombolysis were noted. Indicators of the right heart strain on computed tomography and echocardiogram, as well as the degree of pulmonary vascular obstruction, were recorded before and after CDT. Thirty-day mortality and occurrence of bleeding events were recorded. RESULTS: Nine (30%) patients had 3 or more minor contraindications to thrombolysis and 14 (47%) had major surgery in the month prior to CDT. Right ventricular systolic pressure and vascular obstruction decreased significantly after CDT. There was a significant decrease in the proportion of patients with right ventricular dilation or hypokinesis. Decrease in pulmonary vascular obstruction was associated with nadir of fibrinogen level. No patients experienced major or moderate bleeding attributed to CDT. CONCLUSION: Catheter-directed thrombolysis is an effective therapy in rapidly alleviating the right heart strain that is associated with increased mortality and long-term morbidity in patients with pulmonary embolism with minimal bleeding risk. Catheter-directed thrombolysis is a safe alternative to systemic thrombolysis in patients with risk factors for bleeding such as prior surgery. Future studies should examine the safety of CDT in patients with contraindications to systemic thrombolysis.

Multimodality peak lctal vital signs during video-EEG monitoring.

PURPOSE: To assess and compare peak, multimodal ictal vital signs (iVS) during epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES). METHODS: Between 4/1/2010 and 4/1/2011, 183 adults had video-EEG monitoring, with 96 consecutive patients meeting inclusion criteria. Heart rate (HR), oxygen saturation (SaO2), and blood pressure (BP) were obtained at baseline and during an ictus. The motor semiology of each ES and PNES was also assessed. Student t-test, Fischer's Test, Wilcoxon Test (p=<0.05), and linear regression provided statistical correlation. RESULTS: The 46 patients with ES and 50 patients with PNES had similar baseline VS. Generalized tonic-clonic ES had the highest absolute iVS. ES yielded a higher absolute ictal HR (p=0.0004) and lower SaO2 nadir (p=0.003) than PNES. Systolic and diastolic BP did not differ between groups (p=NS). The upper ranges of iS-BP attained a maximum value of 195/135mm Hg in ES and 208/128mmHg in PNES. For ES, the change in ictal HR was inversely correlated with a reduction in ictal SaO2 (CC= -0.4; p=0.003). In PNES, ictal HR correlated with systolic BP (CC=0.6; p=<0.0001), but not ictal SaO2. CONCLUSION: The inverse relationship between ictal HR and ictal SaO2 in ES suggests a neurobiological difference, and the concept of intrinsic cardio-respiratory dysfunction in patients with epilepsy. The significantly raised peak elevations in ictal HR and ictal systolic BP during PNES demonstrates the potential for serious adverse outcomes if attacks are prolonged.

Fibromyalgia and seizures.

The purpose of this case-matched study was to determine how frequently fibromyalgia is associated with different paroxysmal neurological disorders and explore the utility of fibromyalgia as a predictor for the diagnosis of psychogenic non-epileptic seizures. The billing diagnosis codes of 1,730 new, non-selected patient encounters were reviewed over a three-year period for an epileptologist in a neurology clinic to identify all patients with historical diagnoses of fibromyalgia. The frequency with which epileptic seizures, psychogenic non-epileptic seizures, and physiological non-epileptic events were comorbid with fibromyalgia was assessed. Age and gender case-matched controls were used for a between-group comparison. Wilcoxon tests were used to analyse interval data, and Chi-square was used to analyse categorical data (p<0.05). Fibromyalgia was retrospectively identified in 95/1,730 (5.5%) patients in this cohort. Females represented 95% of the fibromyalgia sample (age: 53 years; 95% CI: 57, 51). Forty-three percent of those with fibromyalgia had a non-paroxysmal, neurological primary clinical diagnosis, most commonly chronic pain. Paroxysmal events were present in 57% of fibromyalgia patients and 54% of case-matched controls. Among patients with fibromyalgia and paroxysmal disorders, 11% had epileptic seizures, 74% had psychogenic non-epileptic seizures, and 15% had physiological non-epileptic events, compared to case-matched controls with 37% epileptic seizures, 51% psychogenic non-epileptic events, and 12% physiological non-epileptic events (p = 0.009). Fibromyalgia was shown to be a predictor for the diagnosis of psychogenic non-epileptic seizures in patients with undifferentiated paroxysmal spells. However, our results suggest that the specificity and sensitivity of fibromyalgia as a marker for psychogenic non-epileptic seizures in a mixed general neurological population of patients is less than previously described.

Focal seizures without awareness.

OBJECTIVE: To characterize patients with seizures that only occur without their awareness (SWA). METHODS: Twenty-four patients with SWA were retrospectively identified by chart review and subsequently underwent video-EEG monitoring (VEM). Eleven patients met selection criteria for SWA and were never aware of any seizures. A case-matched control group of patients who were always aware (SA) was used for comparison. Statistical analysis included Pearson's Chi-square, Fisher's Exact, and Mann-Whitney. RESULTS: Patients with SWA were older at seizure diagnosis than those with SA (p=0.04), were less often referred for evaluation of seizures or epilepsy (p=0.04), and were referred faster for VEM, despite SWA were significantly less likely to include motor manifestations (p=0.0004). SWA more often had temporal lobe onsets (p<0.0001) with left lateralization on ictal EEG (p<0.0001). At final follow up, patients with SWA had tried fewer antiseizure drugs (p=0.03), but reported seizure freedom as often as patients with SA (p=0.4). SIGNIFICANCE: We suggest that patients with SWA have a unique epilepsy syndrome. Patients with absent recall were older, referred later, had fewer motor signs, and dominant hemisphere limbic localization than patients with SA, but fewer antiseizure drugs are used in treatment. Patients with SWA can be detected from the clinical history, though serial VEM is needed to validate effective management.