Sleep Features on Continuous Electroencephalography Predict Rehabilitation Outcomes After Severe Traumatic Brain Injury.

OBJECTIVE: Sleep characteristics detected by electroencephalography (EEG) may be predictive of neurological recovery and rehabilitation outcomes after traumatic brain injury (TBI). We sought to determine whether sleep features were associated with greater access to rehabilitation therapies and better functional outcomes after severe TBI. METHODS: We retrospectively reviewed records of patients admitted with severe TBI who underwent 24 or more hours of continuous EEG (cEEG) monitoring within 14 days of injury for sleep elements and ictal activity. Patient outcomes included discharge disposition and modified Rankin Scale (mRS). RESULTS: A total of 64 patients underwent cEEG monitoring for a mean of 50.6 hours. Status epilepticus or electrographic seizures detected by cEEG were associated with poor outcomes (death or discharge to skilled nursing facility). Sleep characteristics were present in 19 (30%) and associated with better outcome (89% discharged to home/acute rehabilitation; P = .0002). Lack of sleep elements on cEEG correlated with a poor outcome or mRS > 4 at hospital discharge (P = .012). Of those patients who were transferred to skilled nursing/acute rehabilitation, sleep architecture on cEEG associated with a shorter inpatient hospital stay (20 days vs 27 days) and earlier participation in therapy (9.8 days vs 13.2 days postinjury). Multivariable analyses indicated that sleep features on cEEG predicted functional outcomes independent of admission Glasgow Coma Scale and ictal-interictal activity. CONCLUSION: The presence of sleep features in the acute period after TBI indicates earlier participation in rehabilitative therapies and a better functional recovery. By contrast, status epilepticus, other ictal activity, or absent sleep architecture may portend a worse prognosis. Whether sleep elements detected by EEG predict long-term prognosis remains to be determined.

Treated pulmonary arteriovenous malformations: patterns of persistence and associated retreatment success.

PURPOSE: To determine the relative frequencies of persistence patterns in treated pulmonary arteriovenous malformations (PAVMs) and to assess whether there is a difference in retreatment outcomes between PAVMs persisting via recanalization and those persisting via reperfusion. MATERIALS AND METHODS: Between May 2003 and May 2011, 23 patients (10 male, 13 female; mean age, 44 years ± 18 [standard deviation]; age range, 12-72 years) who had PAVM embolization, persistence by computed tomography (CT), and a follow-up pulmonary arteriogram were included. This retrospective study was approved by the institutional review board and was fully HIPAA compliant. PAVMs were categorized as having recanalization, defined as persistence maintained by flow through a previously placed coil nest; reperfusion, defined as persistence through small feeders from adjacent normal pulmonary arteries; or incomplete treatment. Fifty-three persistent PAVMs were characterized; 38 of which had postretreatment CT data (median follow-up, 1 year). The retreatment success rate, defined by sac shrinkage on CT images, was assessed. RESULTS: Recanalization was the most common pattern, occurring in 91% (n = 48) of 53 PAVMs. Pulmonary-to-pulmonary reperfusion occurred in 24% (n = 13) of 53 PAVMs. Angioarchitecture, coil-sac distance, coil number, and feeder diameter did not significantly differ between recanalized and reperfused PAVMs. There was a significant (P = .014) difference in retreatment success; retreatment was successful in 84% (n = 27) of 32 recanalized PAVMs but only 44% (n = 4) of nine reperfused PAVMs. CONCLUSION: Recanalization through previously placed coils is the most common pattern of PAVM persistence and responds best to retreatment. Pulmonary-to-pulmonary reperfusion is less common and more difficult to re-treat successfully. Online supplemental material is available for this article.