Neurohospitalist最新文献

Background: Sialorrhea is associated with various neurological conditions. Among critically ill patients with acute neurological injuries (ANI), sialorrhea leads to several adverse consequences, including extubation failure, inability to initiate non-invasive ventilation, aspiration pneumonia and prolonged hospitalization. Botulinum toxin (BoTN) injections can reduce salivary production. Both BoTN-A and BoTN-B are effective in managing sialorrhea among patients with neurogenic dysphagia. BoTN utilization for sialorrhea in critically ill adult ANI patients is not well-studied. Purpose: The purpose of this study to evaluate the safety and feasibility of using BoTN-A salivary injections to reduce sialorrhea in ANI patients. Research Design: In this case series, we retrospectively reviewed the off-label use of BoTN-A for sialorrhea in ANI patients at the University of North Carolina Neurosciences Intensive Care Unit. Study Sample: Six patients with ANI who received BoTNA treatment for neurogenic sialorrhea in absence of infection and medications with known side-effect of sialorrhea. Data Collection: For safety evaluation, we reviewed any documented adverse effects of BoTN-A injection. For efficacy, we evaluated the drooling severity, suctioning frequency, oxygen requirements, continued days on the ventilator, and pneumonia diagnoses. Results: All patients had reduction in their documented drooling and suctioning requirements following BoTN-A injection. None had adverse events associated with BoTN-A injections. All patients experienced recurrent ventilator-associated pneumonias prior to BoTN-A injections whereas four patients had no pneumonia events after injections. Also, two patients were successfully weaned of oxygenation prior to discharge. Conclusions: This case series highlights the safety and potential efficacy of salivary gland BoTN-A for reducing refractory sialorrhea among critically ill ANI patients. Future studies are needed to evaluate whether sialorrhea reduction can lead to reduced hospital complications and overall length of hospital stay.

Streptococcus pneumoniae is the leading cause of community-acquired bacterial meningitis across all age groups. Despite appropriate antibiotic therapy, the prognosis for pneumococcal meningitis remains poor. While common acute complications include cerebral edema, brain herniation, ventriculitis, hydrocephalus, and cerebral infarctions, hemorrhagic events are rarely reported. We present a case of a young male with S. pneumoniae meningitis, who developed diffuse cerebral microhemorrhages, an extremely rare complication. Despite culture-guided antibiotic therapy, the patient's condition deteriorated, requiring mechanical ventilation. Magnetic resonance imaging revealed diffuse cerebral microhemorrhages, prompting intensive supportive care. Prolonged mechanical support and a two-week antibiotic therapy led to gradual recovery, and the patient was discharged without neurological sequelae. This case highlights the importance of early imaging and timely intervention in managing rare complications of bacterial meningitis.

Background: Patients with neuromuscular disorders often require gastrostomy tube placement for feeding but routinely have contraindication to sedation due to poor airway control with intubation avoided at the risk of ventilator dependence.

Purpose: To assess the feasibility of percutaneous gastrostomy tube (G-tube) placement using only local anesthesia in patients with neuromuscular dysfunction.

Research design: A retrospective chart review was performed from 2013 to 2019 for all patients who underwent percutaneous G-tube placement under local anesthesia only.

Study sample: 12 patients (6 females, 6 males; mean age = 52.3 ± 21.8) with neuromuscular disorders underwent G-tube placement with only local anesthesia.

Data collection: Data collected included demographic data, medical history (source of neuromuscular dysfunction), procedural information, and complications.

Results: Technical success was achieved in 100% of patients with no major complications.

Conclusion: Placement of a percutaneous gastrostomy tube using only local anesthesia is safe and feasible in patients who have a contraindication to sedation due to poor airway control and for whom intubation is avoided due to risk of ventilator dependence.

Myelin oligodendrocyte glycoprotein-associated disorders (MOGAD) are autoimmune diseases that often manifest in the context of infections. They can also arise less commonly following vaccination but even more rarely in a paraneoplastic context. Herein, we will report a patient presenting with subacute inflammatory myelopathy after a fourth dose of the mRNA COVID-19 vaccine. Concurrently, a diagnosis of MOGAD was made with a metastatic abdominal seminoma. The patient was acutely treated with high-dose steroids followed by plasma exchange therapy and was subsequently started on a chemotherapy regimen for the underlying germ cell tumor. The patient had a complete resolution of neurological symptoms upon the last follow-up. Overall, 72 cases of COVID-19 vaccination associated with MOGAD were analyzed (median age at onset 39 years old; female to male ratio = 1.2:1). All cases occurred in adults except for an adolescent, with the majority occurring after vaccination with ChAdOx nCoV-19 (87%), and an average temporal profile between vaccination and symptom onset of 19 days. There were no reported cases after the third or fourth doses, and most patients were diagnosed with new-onset MOGAD after their first vaccine (76%). Although COVID-19 vaccination could be a potential causality, there are significant discrepancies between the reported cases and this patient, alongside the unlikely causality assessment obtained with the Bradford Hill criteria. Vaccination could unmask potential pre-existing autoimmune diseases, such as in this patient, where myelopathy was most likely part of a paraneoplastic syndrome associated with a newly diagnosed seminoma.

Purpose: Neurolisteriosis is a difficult neurologic infectious disease to diagnose. Here, we present a case in which the diagnosis was suspected, but repeated testing for the pathogen was negative. Ultimately the diagnosis was made after the patient iatrogenically worsened. Results: This prompted an investigation into the widely used diagnostic test, the BioFire© Meningitis/Encephalitis Panel. Although the company reports high sensitivities and specificities for the panel, real world studies have demonstrated insufficient evidence that all 14 pathogens tested on the panel have similar results. Conclusion: This case is a reminder of the heuristics involved in medicine and how with every medical advancement, clinicians should always go back to the fundamentals of history-taking and physical examinations to ensure no steps have been overlooked in the diagnosis and management of challenging cases.

Background: Intraventricular hemorrhage is a calamitous type of stroke where bleeding into the ventricular system can be defined as: primary, if confined within the ventricles; or secondary, due to intracerebral hemorrhage extending from adjacent parenchyma. Intraventricular blood clot can lead to secondary insult and inflammatory responses that culminates in hydrocephalus as the most common cause of death.

Purpose: THerein, we report a patient with a high modified Graeb scale and low Glasgow coma scale. She spontaneously recanalized her fourth ventricle, decompressed her reticular activating system with remarkable spontaneous bilateral eye opening, and a consequently experienced a halfway drop in her mGS.

Results: This is the first reported case of a spontaneous recanalization of 4th ventricle obstruction secondary to IVH without intervention and subsequent dramatic neurological improvement. We believe that the apixaban primarily preserved the liquid state of hemorrhage and her presumed elevated ICP was sufficient to push out the liquified blood in the 4th ventricle into the upper spinal canal , recanalizing the 4th ventricle by continuously creating downward CSF pressure waves. Given the RAS location around the 4th ventricle, we hypothesize spontaneous decompression from the clot lysis triggered the RAS activation with sudden arousal manifested as spontaneous bilateral eyes opening. Hence, we refer to this as the reticular activating system reactivation after ventricular hemorrhage evacuation, or simply the "REVIVE" phenomenon.

Conclusion: This dramatic improvement from coma to awake state is worthy of recognition for future neurotherapeutic interventions.

Background and purpose: Though Event Monitors (EM) and Implantable Loop Recorders (ILR) are prevalent in stroke workups, complex processes to obtain placement of these device might result in delays. Our aim was to determine if the CONNECT (Coordinating Options for Neurovascular patients Needing Electrophysiology Consults and Treatments) pathway could improve Stroke-to-Electrophysiology (EP) communications, increase EM and ILR device placements prior to discharge, shorten placement time, and preserve satisfaction.

Methods: We assessed device placements when an EP consult was obtained [Pre-CONNECT (5/1/21-4/30/22), CONNECT (5/1/22-4/30/23)] for patients with stroke. In the Pre- period, consults were sent via EPIC electronic medical record (EMR), with additional direct communication when desired. In the CONNECT period, the pathway and module allowed for immediate communication between services. Outcomes included case rate, times, length of stay, and satisfaction. Hospital reports detailed Order to Activation (O-A) days. EM report review was used to obtain O-A time. Clinician satisfaction was assessed using Qualtrics survey. Patient satisfaction was assessed with Hospital Consumer Assessment of Health care Clinicians and Systems (HCAHPS) survey. Man-Whitney U test was used.

Results: 78 patients were included (30EM(38.5%), 48ILR(61.5%)). Age was 68 years (P = 0.58). For ILRs, inpatient placements prior to discharge increased (3Pre vs 51 CONNECT; P < 0.0001) as did outpatient placements (5 vs 16; P = 0.02). Order to Activation (O-A) time savings were significant for ILR overall (32 days vs 1 day; P = 0.03) and for Inpatient EM (13 days vs 3 days; P = 0.003). Time for consultant to view was 4 min and to respond was 6 min. Devices were placed at a median 6 hrs 32 min (EM: 4 hrs 19 min; ILR:7 hrs36 min). All (12/12) clinicians preferred the technique. Patient satisfaction improved on 13/19 (68%) questions.

Conclusions: There was a 1600% increase in ILR placements prior to discharge that was associated with the time period that the CONNECT process was in place. The robust improvement in ILR placements prior to discharge, high satisfaction, ease of use, closed loop communication, and respect for autonomy allowing more organic parallel discussions with patients improved clinician workflow which could potentially improve future risk reduction strategies.

Background: In this COVID-19 Critical Care Consortium (CCCC) sub-study, we qualified neurological complications associated with SARS-CoV2 infection.

Methods: The CCCC is an international, multicenter study. Eligible patients were COVID-19 patients admitted to intensive care units (ICU) across 23 centers between 1/7/2020 to 6/23/2022. Incidence of neurological complications was estimated as number of events per hospital days and per admission using Poisson regression. Associations between neurological complications and risk factors were assessed using multivariable Poisson regression.

Results: 713 patients were included. Median age = 56 years (interquartile range (IQR) = 45-65). Neurological complications reported in 61/480 patients (12.7%) with the majority being ischemic stroke (2.9%), intracranial hemorrhage (ICH) (2.8%), and seizures (2.6%). Multivariable analysis for neurological complications per admitted days showed comorbid neurological conditions (incidence rate ratio (IRR) = 6.35, 2.57-15.7) were an independent risk factor for ischemic stroke. Extracorporeal membrane oxygenation (IRR = 5.32, 1.52-18.6), low-middle income countries (LMIC) vs high income countries (HIC) (IRR = 4.70, 1.62-13.7), and age >55 (IRR = 3.66, 1.23-10.9) were independent risk factors for ICH. Co-morbid neurological conditions (IRR = 3.43, 1.11-10.6), LMIC vs HIC (IRR = 8.69, 2.15-35.2), July-December 2020 vs January-June 2020 (IRR = 0.17, 0.04-0.69) and age >55 (IRR = 4.05, 1.15-14.3) were independent risk factors for seizure.

Conclusions: Decision-making should incorporate salient risk factors to inform management of SARS-CoV2 infection and avoid neurological complications.

Background: and Purpose: Episodes of unresponsiveness are one of several criteria used to diagnose dementia with Lewy bodies and are also seen in people with Parkinson's disease dementia. Patients examined during episodes of coma, whose evaluations found no other explanation than the neurological disorder, have not been described. This paper describes four cases, seen in the past two years. The objective is to bring this uncommon phenomenon to the attention of hospital based neurologists and to demonstrate that this may not be due to autonomic dysfunction.

Methods: These are brief case descriptions by medical personnel observing affected patients supplemented by family reports of similar episodes described on the internet.

Results: Four cases are described, all older men with either dementia with Lewy bodies or Parkinson's disease dementia, who had single, or multiple episodes of otherwise unexplained coma and were examined during a spell. IRB approval waived.

Conclusions: Episodic coma may occur in demented patients with an alpha-synucleinopathy and is the likely explanation when evaluations have found no other cause. This information will reassure the family and patient that this is the likely explanation but that spells may recur.