Aaron S. Zweig, James S. Stanley, Ronak Patel, John Agola, Michael R Halstead
Background: Pipeline flow diverters (PFDs) are becoming increasingly common. Antiplatelet medication is required to minimize periprocedural ischemic events. Short-acting GPIIb/IIIa inhibitors are frequently administered intraprocedurally; however, the role of these agents in postprocedural PFD management in the neurocritical care unit (NCCU) has been overlooked.Case Report: A patient with an unruptured internal carotid artery aneurysm presented for PFD placement. PFD placement was complicated by post-procedure intra-PFD thrombosis and hemispheric ischemia. Aspirin and ticagrelor were restarted, and the surgery department consulted for tracheostomy and percutaneous endoscopic gastrostomy-tube placement. Short-half-life GPIIb/IIIa infusions served as bridges to surgery after aspirin and tirofiban washout.Conclusion: NCCU management of complications of PFD placement remains under-researched. The use of long-acting antiplatelet agents post-PFD limits the safe administration of surgical procedures. Bridging with GPIIb/IIIa infusion may facilitate the safe delivery of intensive care in these cases.
{"title":"Ticagrelor washout bridged with GPIIb/IIIa inhibitor infusion to facilitate surgical care following placement of pipeline flow diverters: a case report","authors":"Aaron S. Zweig, James S. Stanley, Ronak Patel, John Agola, Michael R Halstead","doi":"10.18700/jnc.230016","DOIUrl":"https://doi.org/10.18700/jnc.230016","url":null,"abstract":"Background: Pipeline flow diverters (PFDs) are becoming increasingly common. Antiplatelet medication is required to minimize periprocedural ischemic events. Short-acting GPIIb/IIIa inhibitors are frequently administered intraprocedurally; however, the role of these agents in postprocedural PFD management in the neurocritical care unit (NCCU) has been overlooked.Case Report: A patient with an unruptured internal carotid artery aneurysm presented for PFD placement. PFD placement was complicated by post-procedure intra-PFD thrombosis and hemispheric ischemia. Aspirin and ticagrelor were restarted, and the surgery department consulted for tracheostomy and percutaneous endoscopic gastrostomy-tube placement. Short-half-life GPIIb/IIIa infusions served as bridges to surgery after aspirin and tirofiban washout.Conclusion: NCCU management of complications of PFD placement remains under-researched. The use of long-acting antiplatelet agents post-PFD limits the safe administration of surgical procedures. Bridging with GPIIb/IIIa infusion may facilitate the safe delivery of intensive care in these cases.","PeriodicalId":33246,"journal":{"name":"Journal of Neurocritical Care","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48260589","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
E. Ko, Il-Jung Hwang, Jung-Woo Kim, Ju-Suck Lee, D. Jung, S. Yoo
Background: Neurofibromatosis type 1 (NF1) is a genetic disorder with diverse phenotypic manifestations. Cerebral vasculopathy is one of the multisystem involvements often overlooked unless symptomatic. Case Report: A 28-year-old male patient with prolonged NF1 complained of right-hand position-specific rhythmic tremor after surviving an ipsilateral cerebellar arteriovenous malformation (AVM) hemorrhagic transformation. Not only did he suffer rupture of the infratentorial vasculopathy but he also endured asymmetric supratentorial occlusive vessel changes in Moyamoya syndrome. Due to contralateral limb clumsiness, his right hemispheric vasculature was revascularized by encephaloduroarteriosynangiosis 13 years before the AVM rupture.Conclusion: This case report describes exceptional NF1 CNS involvement where the cerebral vasculature had concomitant Moyamoya syndrome and unilateral cerebellar AVM in a single patient. Cerebral vasculopathy should be surveyed and adequately addressed during the follow-up of chronic NF1, as it can cause irreversible sequelae or can be life-threatening.
{"title":"Concomitant moyamoya syndrome and infratentorial arteriovenous malformation in a neurofibromatosis type 1 patient: a case report","authors":"E. Ko, Il-Jung Hwang, Jung-Woo Kim, Ju-Suck Lee, D. Jung, S. Yoo","doi":"10.18700/jnc.230018","DOIUrl":"https://doi.org/10.18700/jnc.230018","url":null,"abstract":"Background: Neurofibromatosis type 1 (NF1) is a genetic disorder with diverse phenotypic manifestations. Cerebral vasculopathy is one of the multisystem involvements often overlooked unless symptomatic. Case Report: A 28-year-old male patient with prolonged NF1 complained of right-hand position-specific rhythmic tremor after surviving an ipsilateral cerebellar arteriovenous malformation (AVM) hemorrhagic transformation. Not only did he suffer rupture of the infratentorial vasculopathy but he also endured asymmetric supratentorial occlusive vessel changes in Moyamoya syndrome. Due to contralateral limb clumsiness, his right hemispheric vasculature was revascularized by encephaloduroarteriosynangiosis 13 years before the AVM rupture.Conclusion: This case report describes exceptional NF1 CNS involvement where the cerebral vasculature had concomitant Moyamoya syndrome and unilateral cerebellar AVM in a single patient. Cerebral vasculopathy should be surveyed and adequately addressed during the follow-up of chronic NF1, as it can cause irreversible sequelae or can be life-threatening.","PeriodicalId":33246,"journal":{"name":"Journal of Neurocritical Care","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42616929","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Amélie Giudicelli-Bailly, Chiara Della Badia, M. Augsburger, H. Quintard, R. Giraud, P. De Stefano
Background: Barbiturate poisoning is rare but potentially fatal. Case Report: We reported a case of barbiturate poisoning in a 28-year-old woman who recovered from lethal pentobarbital deliberate self-poisoning. The initial blood pentobarbital concentration was 61 mg/L, corresponding to a potentially lethal dose. Despite the ingestion of a high dose of pentobarbital, the electroencephalogram revealed an unattended pattern compatible with possible nonconvulsive status epilepticus. Following resuscitation maneuvers, appropriate care, and antiseizure medication, the patient awakened after 7 days. The evolution was excellent without neurological deficits at 2 months.Conclusion: Despite the expected and known effects of high-dose pentobarbital in reducing and suppressing cortical activity in the brain, the present case demonstrates that lethal dose of pentobarbital may have an epileptogenic effect. Our hypothesis was that the mechanism of the origin of such a picture is a relatively abrupt decrease in toxic doses of pentobarbital, resulting in a withdrawal phenomenon.
{"title":"Unexpected epileptogenic effect of lethal doses of pentobarbital: a case report","authors":"Amélie Giudicelli-Bailly, Chiara Della Badia, M. Augsburger, H. Quintard, R. Giraud, P. De Stefano","doi":"10.18700/jnc.230019","DOIUrl":"https://doi.org/10.18700/jnc.230019","url":null,"abstract":"Background: Barbiturate poisoning is rare but potentially fatal. Case Report: We reported a case of barbiturate poisoning in a 28-year-old woman who recovered from lethal pentobarbital deliberate self-poisoning. The initial blood pentobarbital concentration was 61 mg/L, corresponding to a potentially lethal dose. Despite the ingestion of a high dose of pentobarbital, the electroencephalogram revealed an unattended pattern compatible with possible nonconvulsive status epilepticus. Following resuscitation maneuvers, appropriate care, and antiseizure medication, the patient awakened after 7 days. The evolution was excellent without neurological deficits at 2 months.Conclusion: Despite the expected and known effects of high-dose pentobarbital in reducing and suppressing cortical activity in the brain, the present case demonstrates that lethal dose of pentobarbital may have an epileptogenic effect. Our hypothesis was that the mechanism of the origin of such a picture is a relatively abrupt decrease in toxic doses of pentobarbital, resulting in a withdrawal phenomenon.","PeriodicalId":33246,"journal":{"name":"Journal of Neurocritical Care","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45127830","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Demyelinating events expressed as abnormal thermoregulatory responses are rare, but intractable fever in myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is very rarely reported.Case Report: A 56-year-old woman presented with quadriparesis with acroparesthesia. During the admission, fever developed and persisted for 2 days despite the administration of high-dose antipyretics. Brain magnetic resonance imaging (MRI) showed hyperintense lesions involving the upper brainstem. A diagnosis of MOGAD was made according to the clinical characteristics and presence of seropositive MOG antibody. After administration of oral bromocriptine (2.5 mg/day), fever was slowly controlled for a few days.Conclusion: The present case explained that persistent fever in MOGAD could manifest as an uncommon manifestation. The lesion in the upper brainstem within the brain MRI could be thought of as a lesion anterior to the periaqueductal gray and the lesion at that site could be the cause of the patient's persistent fever with unknown origin.
{"title":"Myelin oligodendrocyte glycoprotein antibody-associated disease manifesting as intractable fever managed by bromocriptine: a case report","authors":"Jin San Lee, Sukyoon Lee, Seong-il Oh","doi":"10.18700/jnc.230020","DOIUrl":"https://doi.org/10.18700/jnc.230020","url":null,"abstract":"Background: Demyelinating events expressed as abnormal thermoregulatory responses are rare, but intractable fever in myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is very rarely reported.Case Report: A 56-year-old woman presented with quadriparesis with acroparesthesia. During the admission, fever developed and persisted for 2 days despite the administration of high-dose antipyretics. Brain magnetic resonance imaging (MRI) showed hyperintense lesions involving the upper brainstem. A diagnosis of MOGAD was made according to the clinical characteristics and presence of seropositive MOG antibody. After administration of oral bromocriptine (2.5 mg/day), fever was slowly controlled for a few days.Conclusion: The present case explained that persistent fever in MOGAD could manifest as an uncommon manifestation. The lesion in the upper brainstem within the brain MRI could be thought of as a lesion anterior to the periaqueductal gray and the lesion at that site could be the cause of the patient's persistent fever with unknown origin.","PeriodicalId":33246,"journal":{"name":"Journal of Neurocritical Care","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44558394","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Luis Espinosa, Mario Gómez, Adrián C. Zamora, Daniel Molano‐Franco
Status epilepticus (SE) is a neurological emergency with serious consequences for neuronal tissues, therefore, it is considered the most serious manifestation of epilepsy. The response to treatment, its evolution time and duration, and the need to use one or more antiseizure drugs define SE as refractory or super-refractory. Ketamine has been used in SE management since the 90s when an article describing its use in treating SE was published. Since then, at least 24 publications have reported the use of ketamine for the treatment of SE in both adult and pediatric patients. This scoping review seeks to synthesize information on the use of drugs in super-refractory SE, specifically ketamine. Twenty articles were chosen for the final document construction. Few studies have investigated the use of ketamine in refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE). Most of the information comes from retrospective case series studies, mostly with small sample sizes, and although the information is heterogeneous, it points to the efficacy of ketamine as a third-line drug in RES and SRSE, in controlling seizures.
{"title":"Refractory and super-refractory status epilepticus and evidence for the use of ketamine: a scope review","authors":"Luis Espinosa, Mario Gómez, Adrián C. Zamora, Daniel Molano‐Franco","doi":"10.18700/jnc.230003","DOIUrl":"https://doi.org/10.18700/jnc.230003","url":null,"abstract":"Status epilepticus (SE) is a neurological emergency with serious consequences for neuronal tissues, therefore, it is considered the most serious manifestation of epilepsy. The response to treatment, its evolution time and duration, and the need to use one or more antiseizure drugs define SE as refractory or super-refractory. Ketamine has been used in SE management since the 90s when an article describing its use in treating SE was published. Since then, at least 24 publications have reported the use of ketamine for the treatment of SE in both adult and pediatric patients. This scoping review seeks to synthesize information on the use of drugs in super-refractory SE, specifically ketamine. Twenty articles were chosen for the final document construction. Few studies have investigated the use of ketamine in refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE). Most of the information comes from retrospective case series studies, mostly with small sample sizes, and although the information is heterogeneous, it points to the efficacy of ketamine as a third-line drug in RES and SRSE, in controlling seizures.","PeriodicalId":33246,"journal":{"name":"Journal of Neurocritical Care","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48509028","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Coronavirus disease 2019 (COVID-19) has resulted in social, economic, medical, and psychological changes. New-onset altered level of consciousness (ALC) is a classical presentation in real-world medicine. This study investigated changes in ALC in the emergency room (ER) in the periods before (BC) and after (AC) COVID-19.Methods: This was a retrospective study of patients with ALCs who visited the ER of a tertiary referral center, and their medical records BC and AC were compared. A consortium allocated and analyzed the etiologies of ALC in a case-by-case discussion. The time point for etiological assessment was the time of discharge from the ER.Results: In total, 1,936 patients with ALCs (731 and 1,205 in BC and AC, respectively) were investigated. The most common etiology was systemic infection (25.9%), followed by metabolic causes (20.8%). Systemic infections (22.9% vs. 30.8%, P<0.001) and stroke (14.6% vs. 18.2%, P=0.037) were lower in AC than in BC, respectively, whereas rates of toxicity (15.4% vs. 6.0%, P<0.001) and traumatic brain injury (TBI; 5.9% vs. 0.8%, P<0.001) were higher in AC than in BC. The overall mortality rate of ALC in the ER was 18.5%.Conclusion: This study demonstrated that the major etiologies of ALC in the ER were extra-cranial (58.5%). The mortality of ALC in the ER and the incidence of toxic cause and TBI increased in AC, suggesting a change in medical circumstances after the Pandemic.
背景:2019冠状病毒病(COVID-19)造成了社会、经济、医疗和心理方面的变化。新发意识水平改变(ALC)是现实医学中的经典表现。本研究调查了COVID-19 (BC)之前和(AC)之后急诊室(ER) ALC的变化。方法:这是一项回顾性研究，就诊于三级转诊中心急诊室的ALCs患者，比较他们的医疗记录BC和AC。一个联盟在个案讨论中分配和分析了ALC的病因。病因评估时间点为出院时间。结果:共调查了1936例ALCs患者(BC和AC分别为731例和1205例)。最常见的病因是全身感染(25.9%)，其次是代谢原因(20.8%)。AC组的全身性感染(22.9%比30.8%，P<0.001)和卒中(14.6%比18.2%，P=0.037)分别低于BC组，而毒性发生率(15.4%比6.0%，P<0.001)和创伤性脑损伤(TBI;5.9% vs. 0.8% (P<0.001)， AC高于BC。急诊ALC的总死亡率为18.5%。结论:本研究表明，ER区ALC的主要病因是颅外(58.5%)。急诊区ALC的死亡率以及AC区毒性原因和TBI的发生率均有所增加，这表明大流行后医疗环境发生了变化。
{"title":"The etiology and mortality of altered level of consciousness in the emergency room: before and after coronavirus disease","authors":"Y. Jeon, J. Jeon, C. Jung, Keuntae Kim","doi":"10.18700/jnc.230008","DOIUrl":"https://doi.org/10.18700/jnc.230008","url":null,"abstract":"Background: Coronavirus disease 2019 (COVID-19) has resulted in social, economic, medical, and psychological changes. New-onset altered level of consciousness (ALC) is a classical presentation in real-world medicine. This study investigated changes in ALC in the emergency room (ER) in the periods before (BC) and after (AC) COVID-19.Methods: This was a retrospective study of patients with ALCs who visited the ER of a tertiary referral center, and their medical records BC and AC were compared. A consortium allocated and analyzed the etiologies of ALC in a case-by-case discussion. The time point for etiological assessment was the time of discharge from the ER.Results: In total, 1,936 patients with ALCs (731 and 1,205 in BC and AC, respectively) were investigated. The most common etiology was systemic infection (25.9%), followed by metabolic causes (20.8%). Systemic infections (22.9% vs. 30.8%, P<0.001) and stroke (14.6% vs. 18.2%, P=0.037) were lower in AC than in BC, respectively, whereas rates of toxicity (15.4% vs. 6.0%, P<0.001) and traumatic brain injury (TBI; 5.9% vs. 0.8%, P<0.001) were higher in AC than in BC. The overall mortality rate of ALC in the ER was 18.5%.Conclusion: This study demonstrated that the major etiologies of ALC in the ER were extra-cranial (58.5%). The mortality of ALC in the ER and the incidence of toxic cause and TBI increased in AC, suggesting a change in medical circumstances after the Pandemic.","PeriodicalId":33246,"journal":{"name":"Journal of Neurocritical Care","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42101021","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Delayed post-ischemic leukoencephalopathy (DPIL) is a rare complication after mechanical thrombectomy, with no well-established clinical characteristics and patho-mechanism. We explored the characteristics and possible mechanisms in three patients with DPIL. Case Report: Based on the clinical manifestations and laboratory findings including magnetic-resonance imaging, magnetic resonance spectroscopy, electroencephalography, and lumbar puncture, DPIL was diagnosed in three patients. We administered antiplatelet agents and conservative treatment. Cardioembolism, successful recanalization using a balloon guiding catheter, and fluctuating or gradually worsening neurological symptoms in delayed phase between 13 and 70 days were common features of DPIL. Diffusion-weighted imaging and fluid-attenuated inversion recovery showed high-signal intensity in the affected subcortical white matter. Laboratory findings provided no evidence of an epileptic disorder, inflammatory demyelination, or tumorous conditions. Conclusion: This report shows the characteristics and neuroradiologic images of DPIL. Among the various hypotheses, regional hypoxic-ischemic leukoencephalopathy and delayed reperfusion injury might be the patho-mechanism underlying DPIL.
{"title":"Delayed post-ischemic leukoencephalopathy in emergent large-vessel occlusive stroke after mechanical thrombectomy: case reports","authors":"J. Ryu, Dongwhane Lee, S. Kwon, J. Chang","doi":"10.18700/jnc.230011","DOIUrl":"https://doi.org/10.18700/jnc.230011","url":null,"abstract":"Background: Delayed post-ischemic leukoencephalopathy (DPIL) is a rare complication after mechanical thrombectomy, with no well-established clinical characteristics and patho-mechanism. We explored the characteristics and possible mechanisms in three patients with DPIL. Case Report: Based on the clinical manifestations and laboratory findings including magnetic-resonance imaging, magnetic resonance spectroscopy, electroencephalography, and lumbar puncture, DPIL was diagnosed in three patients. We administered antiplatelet agents and conservative treatment. Cardioembolism, successful recanalization using a balloon guiding catheter, and fluctuating or gradually worsening neurological symptoms in delayed phase between 13 and 70 days were common features of DPIL. Diffusion-weighted imaging and fluid-attenuated inversion recovery showed high-signal intensity in the affected subcortical white matter. Laboratory findings provided no evidence of an epileptic disorder, inflammatory demyelination, or tumorous conditions. Conclusion: This report shows the characteristics and neuroradiologic images of DPIL. Among the various hypotheses, regional hypoxic-ischemic leukoencephalopathy and delayed reperfusion injury might be the patho-mechanism underlying DPIL.","PeriodicalId":33246,"journal":{"name":"Journal of Neurocritical Care","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49586207","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Progressive cerebral large-vessel vasculitis in a patient with Sjögren’s syndrome","authors":"Woo Jin Kim, Jin San Lee, Seong-il Oh","doi":"10.18700/jnc.220088","DOIUrl":"https://doi.org/10.18700/jnc.220088","url":null,"abstract":"","PeriodicalId":33246,"journal":{"name":"Journal of Neurocritical Care","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43286774","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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