Neurohospitalist最新文献

Purpose: Evaluate patient, clinical, and treatment variables impacting mortality in patients with brain abscesses.

Background: Brain abscesses are intraparenchymal infectious foci with significant morbidity and mortality. Management includes antimicrobial therapy +/- surgical intervention, and is dependent on suspected pathogen/source, patient factors, and clinician judgement. Treatment type and duration vary substantially and are often guided by imaging, inflammatory markers, and symptoms.

Methods: 186 patients with brain abscesses admitted at a single health system between 2010 and 2022 were analyzed. Patient demographics, clinical course, diagnostic studies, and abscess treatment were assessed for impact on mortality during admission via univariate and stepwise multivariate nominal logistic regression. Secondary outcomes of surgical drainage were evaluated with univariate and multivariate nominal logistic regression, and survival over time of those who received surgical drainage vs those who did not was evaluated with Kaplan-Meier survival analysis.

Results: 10.7% of patients died during initial admission. Intravenous drug use, deep-seated abscess location, and surgical complication were independently predictive of death during admission. Patients without surgical intervention demonstrated increased likelihood of mortality over time but not during admission. Independent predictors of surgical intervention include lack of ventriculitis, larger abscess diameter, non-hematogenous or -pulmonary source, and mass effect.

Conclusions: These findings suggest surgical intervention is generally avoided when infection is systemic, severe, or with intraventricular abscess rupture. Patients with overt symptoms of brain infection were more likely to receive prompt surgical drainage. In our patient population, surgical drainage in addition to antimicrobial therapy did not independently impact inpatient mortality although did impact overall survival.

Cryptococcal meningitis is a leading cause of morbidity and mortality in patients infected with human immunodeficiency virus. In over 90% of cases, it occurs at CD4 T lymphocyte (CD4) cell counts of less than 100 cells/mm³. Cryptococcomas are rare granulomatous lesions that can occur in disseminated central nervous system cryptococcal infection, primarily in immunocompetent hosts. Here we report a case of disseminated cryptococcal meningitis with numerous cryptococcomas mimicking metastases in a patient with HIV and a CD4 count of 115. The patient's serum and cerebrospinal fluid (CSF) cryptococcal antigen, CSF cryptococcal polymerase chain reaction, and serum and CSF cryptococcal cultures were all negative. Brain biopsy pathology confirmed the diagnosis. In this paper, we highlight the importance of early cerebral biopsy in the diagnosis and management of cryptococcoma.

Background and purpose: High quality clinical documentation is a fundamental skill for practicing physicians and important for quality improvement. However, documentation and coding are rarely integrated into medical education curricula and there is a lack of standard neurology curriculum on this topic. We developed and evaluated a teaching session on clinical documentation for neurology resident physicians.

Methods: The education consisted of a didactic session designed by a neurologist with content about risk-adjusted mortality, clinical documentation integrity (CDI), impact of documentation on patients, and neurology-specific documentation guidance. A pre-post survey design was used to compare baseline and post-intervention self-reported knowledge and attitudes.

Results: 61 responses were collected (37 pre- and 24 post-intervention). Residents had increased understanding of the impact of documentation on quality metrics (P = 0.004), risk-adjusted mortality (P < 0.0001), and impact on patients (P = 0.02). Attitude towards CDI education improved significantly (P = 0.0016), as well as agreement that CDI is important to resident physicians (P = 0.003). The portion of residents who agreed training on CDI is useful and valuable increased significantly (P = 0.004). 92% agreed this curriculum was useful, and 96% agreed they understood the role of CDI better after the session.

Conclusions: In this study of a teaching session for neurology residents on clinical documentation, we found this format of teaching was well-received and highly effective in improving resident attitudes and self-reported knowledge.

Subacute-to-chronic gait instability has a broad differential diagnosis. The neurological exam can help elucidate the localization and suggest an underlying etiology of the symptomatology, which can lead to a more focused diagnostic approach. Two patients are described - 1 with a month of worsening difficulty with ambulation that evolved to bilateral hand discoordination and another with 18 months of progressive difficulty with ambulation that also then progressed to involve her bilateral hands. These cases highlight an approach to gait dysfunction with hand discoordination secondary to sensory ataxia. The patients were ultimately diagnosed with copper deficiency myelopathy secondary to zinc excess, and different treatment regimens are discussed.

Objective: To examine the association between housing status and healthcare utilization in individuals presenting with seizure.

Methods: We performed a retrospective cross-sectional analysis of all adults (age >18) presenting to a public hospital emergency department with seizures, defined by ICD-9/10 codes, between 1/1/2016 and 8/03/2019. They were categorized by housing status (people experiencing homelessness [PEH], people with housing). Healthcare utilization outcomes were 30-day re-visit to acute care, discharge disposition, and hospital length of stay for those admitted. We used multivariable linear and logistic regression models adjusting for age, comorbidities, and insurance status.

Results: There were 6483 individuals (2092 [32.3%] PEH). Compared to people with housing, PEH were younger (48.2 vs 50.9, P < .0001), more likely to be a person of color (80.9 vs 75.1%, P < .0001), and have Medicaid (51.4% vs 42.9%, P < .0001). People with housing had a higher prevalence of admission to the intensive care unit (3.6% vs 1.8%, P < .0001). After adjustment, admitted PEH had higher odds of 30-day re-visit (adjusted odds ratio [aOR] 1.87, 95% confidence interval [CI] 1.58, 2.21), shorter length of stay (coef Β-12.87, 95% CI: -22.62, -3.11), and lower odds of being discharged to a facility (aOR 0.37, 95% CI: .26, .55) compared to people with housing.

Conclusion and relevance: PEH with seizures had increased healthcare utilization. Further analysis, including imaging findings, anti-seizure medications prescribed, and presumed etiology, is needed to understand the drivers of healthcare utilization and identify appropriate interventions.

Background/objectives: There is currently no consensus regarding the optimal strategy for reversal of anticoagulation in life-threatening hemorrhage associated with factor XIa (FXIa) inhibitors.

Methods: For this clinical case report, informed consent was obtained from surrogate.

Results and discussion: Here, we present the case of an 82-year-old female who sustained a large subdural hematoma after a fall. Her aPTT on admission was elevated at 90.4 s and remained persistently prolonged at 90.9 s 12-hour after receiving an adequate dose of 4-factor prothrombin complex concentrate (PCC). She was found to have received a factor XIa inhibitor in a clinical trial, and subsequently received recombinant activated factor VII (rFVIIa) 2 mg (45 mcg/kg) as a one-time dose, and tranexamic acid (TXA) 1 g intravenously for reversal given her intracranial bleeding in the setting of trauma complicated by recent factor XIa inhibitor use. However, given her clinical decline and high surgical risk, the patient's family elected to withdraw care and she expired three days later. Reversal of FXIa inhibitors is challenging but may best be achieved using a combination of rFVIIa and TXA.

Practical implications: Clinicians should consider administration of low dose recombinant activated factor VII (rFVIIa) in conjunction with an anti-fibrinolytic inhibitor such as tranexamic acid (TXA) for reversal of life-threatening hemorrhage in bleeding patients with exposure to novel factor XIa inhibitors that are currently in clinical trials.

We describe the case of a 36-year-old woman with a past medical history of low grade right frontal lobe glioma and focal epilepsy presenting with subacute, progressive, multifocal myoclonus and neck and back pain. Unlike her typical seizures, the myoclonus exhibited a distinct semiology, involving both positive and negative muscle jerks affecting multiple limb muscles while sparing the face. In addition, neurological examination revealed low-amplitude, arrhythmic movements of the hands and fingers, resembling minipolymyoclonus. There were no other neurological exam findings, including mental status changes, extrapyramidal signs or signs of myelopathy. Brain and spine MRI indicated leptomeningeal and spinal "drop" enhancing lesions, suggesting likely malignant evolution of the glioma. EEG ruled out a cortical origin of the myoclonus. Pharmacological trials with benzodiazepines and other antiepileptic medications were ineffective. The patient's myoclonus was most likely spinal segmental in origin from meningeal spread of glioma. The spinal roots or anterior horns of the spinal cord may have represented a focus of hyperexcitability responsible for generating minipolymyoclonus. Our case expands the etiological spectrum of non-epileptic myoclonus and minipolymyoclonus to encompass meningeal carcinomatosis and drop metastases from glioma. These cases may occur even without overt signs of myelopathy. Recognizing such presentations holds significance due to the poor prognosis associated with meningeal spread of glioma and the limited response of non-epileptic myoclonus to symptomatic treatments.

Background: Nonmydriatic ocular fundus photography has been studied with demonstrated benefit in the evaluation of emergency department neurological complaints, particularly in triaging headache and focal neurological deficits. Likewise, portable fundus camera usage may be practical for inpatients with neurological complaints, although feasibility has not been studied in a neurology teaching service. Purpose: The objective of this study is to determine if a portable, nonmydriatic fundus camera could be integrated into routine clinical care by neurology inpatient housestaff at a tertiary medical center. Research Design: Housestaff were asked to obtain fundus photographs for patients with specific indications for fundoscopy. Study Sample: During a 1-month pilot period, housestaff were successfully able to upload images from 21 patients, which were reviewed by a neuro-ophthalmology attending, with input from on-call ophthalmology if desired. Results: Surveys of housestaff before (n = 13) and after (n = 12) implementation demonstrated increased confidence in camera operation and in ocular structure identification, description, and interpretation. Thematic analysis on qualitative feedback suggested benefits in clinical (improving fundus visualization, aiding in triage, sharing images with offsite staff), health systems (reducing length of stay, reducing ophthalmology consultations, reduced unnecessary testing), and educational domains (facilitating group discussions of images, sharing photographs with patients). Conclusions: Overall, inpatient portable fundus photography was shown to be feasible and effective for rapid fundus visualization for neurological inpatients, enhancing the ability to share, document, and compare examinations among neurology housestaff. Further work is needed to confirm clinical and educational benefits of portable fundus photography usage by neurology residents, as suggested by this healthcare quality improvement pilot study.

Subacute, painful weakness is a common problem encountered by neurologists and can be associated with systemic symptoms. The patient presented with 6 weeks of progressive neuropathic pain followed by sensory changes and distal-predominant weakness. This case reviews the broad differential for such a presentation and a comprehensive, stepwise approach to diagnosis. Particular attention is paid to the potentially treatable polyradiculoneuropathies, including more recently recognized immune-mediated etiologies. Through this stepwise approach, we review how a definitive diagnosis was made.