Outpatient EEG in Routine Clinical Care of Patients With Stroke-Related Acute Symptomatic Seizure Concerns

PURPOSE

Acute symptomatic seizures (ASyS) after stroke contribute the highest risk to poststroke epilepsy (PSE) development. We investigated the use of outpatient EEG (oEEG) among stroke patients with ASyS concerns.

METHODS

Adults with acute stroke, ASyS concerns (underwent cEEG), and outpatient clinical follow-up were included (study population). Patients with oEEG (oEEG cohort) were analyzed for electrographic findings. Univariable and multivariable analyses helped identify predictors of oEEG use in routine clinical care.

RESULTS

Among 507 patients, 83 (16.4%) underwent oEEG. The independent predictors of oEEG utilization included age (OR = 1.03 [1.01 to 1.05, P = 0.01]), electrographic ASyS on cEEG (OR 3.9 [1.77 to 8.9], P < 0.001), ASMs at discharge (OR 3.6 [1.9 to 6.6], P < 0.001), PSE development (OR 6.6 [3.5 to 12.6], P < 0.001), and follow-up duration (OR = 1.01 [1.002 to 1.02], P = 0.016). Almost 40% of oEEG cohort developed PSE, but only 12% had epileptiform abnormalities. Close to a quarter (23%) of oEEGs were within normal limits.

CONCLUSIONS

One in six patients with ASyS concern after stroke undergoes oEEG. Electrographic ASyS, PSE development, and ASM at discharge are primary drivers of oEEG use. While PSE drives oEEG use, we need systematic, prospective investigation of outpatient EEG's role as prognostic tool for PSE development.

Systematic Literature Review of the Association of Fever and Elevated Temperature with Outcomes in Critically Ill Adult Patients

Although most commonly associated with infection, elevated temperature and fever also occur in a variety of critically ill populations. Prior studies have suggested that fever and elevated temperature may be detrimental to critically ill patients and can lead to poor outcomes, but the evidence surrounding the association of fever with outcomes is rapidly evolving. To broadly assess potential associations of elevated temperature and fever with outcomes in critically ill adult patients, we performed a systematic literature review focusing on traumatic brain injury, stroke (ischemic and hemorrhagic), cardiac arrest, sepsis, and general intensive care unit (ICU) patients. Searches were conducted in Embase® and PubMed® from 2016 to 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including dual-screening of abstracts, full texts, and extracted data. In total, 60 studies assessing traumatic brain injury and stroke (24), cardiac arrest (8), sepsis (22), and general ICU (6) patients were included. Mortality, functional, or neurological status and length of stay were the most frequently reported outcomes. Elevated temperature and fever were associated with poor clinical outcomes in patients with traumatic brain injury, stroke, and cardiac arrest but not in patients with sepsis. Although a causal relationship between elevated temperature and poor outcomes cannot be definitively established, the association observed in this systematic literature review supports the concept that management of elevated temperature may factor in avoidance of detrimental outcomes in multiple critically ill populations. The analysis also highlights gaps in our understanding of fever and elevated temperature in critically ill adult patients.

Cardiac Oscillations Complicating Brain Death Diagnosis

Death by neurologic criteria (DNC) or brain death is a clinical diagnosis. It is often complicated by variations in policies as well as confounders on examination. We discuss here the case of a 27-year-old male who had a cardiac arrest following toxic gaseous exposure. He ultimately progressed to brain death but was identified as having cardiac oscillations during clinical assessments that complicated the diagnosis. We discuss the case as well as the maneuvers used to clarify that the "triggered breaths" on the ventilator were indeed cardiac oscillations.

Impact of acute symptomatic seizures and their management on patient-reported outcomes after stroke

OBJECTIVE

Acute symptomatic seizures (ASyS) after stroke are not uncommon. However, the impact of ASyS and its management with anti-seizure medications (ASMs) on patient-reported outcome measures (PROMs) remains poorly investigated. The objective of our study is to evaluate the association between PROMs and ASyS and ASMs following stroke.

METHODS

We performed a retrospective cohort study of all stroke patients who underwent inpatient continuous EEG (cEEG) monitoring performed due to suspected ASyS, including the ones with observed convulsive ASyS, from 04/01/2012 to 03/31/2018, who completed PROMs within 6 months of hospital discharge. Patient-reported outcome measures, including one Neuro-QoL and six PROMIS v1.0 domain scales, were completed by patients as the standard of care in ambulatory stroke clinics. Since ASMs are sometimes used without clearly diagnosed ASyS, we performed group comparisons based on ASM status at discharge, irrespective of their ASyS status. T-tests or Wilcoxon rank sum tests compared continuous variables across groups and chi-square tests or Fisher's exact tests were used for categorical variables.

RESULTS

A total of 508 patients were included in the study [mean age 62.0 ± 14.1 years, 51.6% female; 244 (48.0%) ischemic stroke, 165 (32.5%) intracerebral hemorrhage, and 99 (19.5%) subarachnoid hemorrhage]. A total of 190 (37.4%) patients were discharged on ASMs. At the time of the first PROM, conducted a median of 47 (IQR = 33-78) days after the suspected ASyS, and 162 (31.9%) were on ASMs. ASM use was significantly higher in patients diagnosed with ASyS. Physical Function and Satisfaction with Social Roles and Activities were the most affected health domains. Patient-reported outcome measures were not significantly different between groups based on ASyS (electrographic and/or convulsive), ASM use at hospital discharge, or ASM status on the day of PROM completion.

SIGNIFICANCE

There were no differences in multiple domain-specific PROMs in patients with recent stroke according to ASyS status or ASM use suggesting the possible lack of the former's sensitivity to detect their impact. Additional research is necessary to determine if there is a need for developing ASyS-specific PROMs.

Postanoxia-Induced Chorea Treated with Intravenous Fentanyl

The case presented is that of a young male with postanoxic brain injury secondary to cocaine overdose who began to exhibit choreiform movements of the left upper extremity. Traditional treatment options for chorea were unsuccessful, leading to the administration of fentanyl, which rapidly resolved the patient's choreiform movements. There is a limited research involving the treatment of chorea in anoxic brain injury as well as fentanyl's role in the movement pathway. We hypothesize that chorea can be caused or exacerbated by opioid withdrawal in a patient with chronic opioid use through modulation of dopamine transmission.

Acute Symptomatic Seizure Associated With Chronic Anti-seizure Medication Use After Stroke

Background:

Patients with acute-symptomatic seizures (ASyS) after stroke are discharged on anti-seizure medications (ASMs) and stay on them for an extended period. We analyzed the current ASM management practice, six months, and at the last follow-up after stroke-related ASyS concerns to identify chronic and long-term ASM use predictors.

Methods:

A single-center, retrospective cohort study of adults who underwent continuous EEG monitoring for ASyS concerns after stroke (04/01/2012 to 03/31/2018) with at least six months of follow-up was performed. ASM use beyond six months after the initial ASyS concern was defined as ‘chronic’ among patients discharged on them. ‘Long-term’ ASM use at the last follow-up in all patients with ASyS concerns was analyzed. Logistic regression and Cox-regression multivariable modeling to analyze predictors of ‘chronic’ and ‘long-term’ ASM use, respectively, was performed.

Results:

A total of 465 (mean age 61.7 ±13.3 years; 52% females) patients (41.9% ischemic stroke, 36.1% ICH, 21.9% SAH) were included. Of the 179 (38.5%) patients discharged on ASMs, 132 (73.7%; 28.4% of study population) had chronic ASM use, despite 90% not experiencing any seizure [post-stroke epilepsy (PSE)] during this time. The independent predictors of chronic ASM use were electrographic ASyS [Odds ratio (OR) = 9.27, 95%CI = 2.53 – 60.4], and female sex (OR = 2.2, 95% CI = 1.02 – 4.83). After a median 61 months (5.1 years) follow-up, 101 (21.7%) patients in the study population were on long-term ASM use, including 67 (14.4%) who developed PSE. Long-term ASM use was associated with NIHSS (OR = 1.5, 95% CI = 1.015 – 1.98), cortical involvement (OR = 1.28, 95% CI = 1.02 – 1.6), convulsive ASyS (OR = 1.46, 95% CI = 1.02 – 2.09), epileptiform findings on outpatient EEG (OR = 4.03, 95% CI = 1.28 – 12.76), and PSE development (OR = 7.06, 95% CI = 3.7 – 13.4).

Conclusions:

Chronic ASM use is highly associated with electrographic, rather than convulsive, ASyS. However, long-term ASM use is independently associated with PSE and its risk factors, including convulsive ASyS. With the ubiquity of stroke-related ASyS concerns in routine clinical practice, comparative effectiveness studies to guide ASM management are needed.

Personalized model to predict seizures based on dynamic and static continuous EEG monitoring data

BACKGROUND/OBJECTIVE

Early recognition of patients who may be at risk of developing acute symptomatic seizures would be useful. We aimed to determine whether continuous electroencephalography (cEEG) data using machine learning techniques such as neural networks and decision trees could predict seizure occurrence in hospitalized patients.

METHODS

This was a single center retrospective cohort analysis of cEEG data in patients aged 18-90 years who were admitted and underwent cEEG monitoring between 2010 and 2019 limited to 72 h excluding those who were seizing at the onset of recording. A total of 41,491 patients were reviewed; of these, 3874 were used to develop the static model and 1687 to develop the dynamic model (half with seizure and half without seizure in each cohort). Of these, 80% were randomly selected as derivation cohorts for each model and 20% were randomly selected as validation cohorts. Dynamic and static machine learning models (long short term memory (LSTM) and Extreme Gradient Boosting algorithm (XGBoost)) based on day-to-day dynamic EEG changes and binary static EEG features over the prior 72 h or until seizure, which ever was earlier, were used.

RESULTS

The static model was able to predict seizure occurrence based on cEEG data with sensitivity and specificity of 0.81 and 0.59, respectively, with an AUC of 0.70. The dynamic model was able to predict seizure occurrence with sensitivity and specificity of 0.72 and 0.80, respectively, and AUC of 0.81.

CONCLUSIONS

Machine learning models could be applied to cEEG data to predict seizure occurrence based on available cEEG data. Dynamic day-to-day EEG data are more useful in predicting seizures than binary static EEG data. These models could potentially be used to determine the need for ongoing cEEG monitoring and to prioritize resources.

Timing of Acute Stroke in COVID-19-A Health System Registry Study

Background and Purpose

The association between SARS-CoV-2 infection and stroke remains unknown. We aimed to compare the characteristics of stroke patients who were hospitalized with Coronavirus Disease 2019 (COVID-19) based on the timing of stroke diagnosis.

Methods

We performed a retrospective analysis of adult patients in a health system registry of COVID-19 who were hospitalized and had imaging-confirmed acute stroke during hospitalization. Baseline characteristics and hospital outcomes were collected and analyzed.

Results

Out of 882 COVID-19 patients who were hospitalized between March 9 to May 17, 2020, 14 patients (2% of all COVID-19 patients and 21% of those who underwent imaging) presented with stroke or developed stroke during hospitalization. Eleven had acute ischemic stroke (AIS) and 3 had acute hemorrhagic stroke. Six patients (43%) presented to the hospital with acute stroke symptoms and were found to have SARS-CoV-2. Compared to patients who presented with AIS, more patients with AIS during hospitalization were male, of older age, had pneumonia and acute respiratory distress syndrome, were severely ill, and had high inflammatory and thrombotic markers (including C reactive protein, D dimer, ferritin, and fibrinogen). Among all patients, hospital mortality was high (50%) and the majority of patients who were discharged had poor neurological outcome.

Conclusions

A distinction should be made between patients who present with acute stroke with concurrent SARS-CoV-2 infection and those who develop stroke as a complication of severe COVID-19. It is likely that a subset of stroke patients will incidentally test positive for the virus given the widespread pandemic.

Characterization of Postanoxic Tonic Eyelid Opening: A Poorly Recognized Prognostic Sign

Background

Postanoxic myoclonus is a known poor prognostic sign, and other postanoxic spontaneous movements have been reported but poorly described. We aim to describe the electroclinical phenomenon of postanoxic eyelid openings in context of its possible prognostic value.

Methods

We collected clinical data on postcardiac arrest patients with suspicious eyelid movements noted on continuous EEG monitoring. The eyelid movements captured on the video were correlated with the EEG findings and final clinical outcome. Neuroimaging data were reviewed when available. We also conducted a thorough literature review on this topic.

Results

A total of 10 patients (5 females) with average age of 56.1 (±14.4) years were included. The mean cardiopulmonary resuscitation duration was 18.9 (±11.3) minutes. Postanoxic eyelid-opening movements occurred at variable intervals (0.5-570 seconds) in each individual. Close examination of eyelid opening (available in 6 patients) revealed them to be tonic movements, lasting an average of 3 (±0.8) seconds and always succeeded the onset of burst of EEG activity in a burst-suppression background. This is a transient phenomenon, lasting a median duration of 30 (interquartile range 7.75-36) hours. MRI findings in 3 patients demonstrated diffuse cortical ischemic injury with relative sparing of the brainstem. All patients died within 2-7 days following cardiac arrest.

Conclusions

Contrary to previous descriptions, the postanoxic tonic eyelid openings (PATEO) are repetitive but nonperiodic, nonmyoclonic movements. Their close and specific temporal correlation with the burst of EEG activity suggests that this could be considered an ictal phenomenon requiring an intact midbrain based on MRI findings.

Long-term electro-clinical profile of sudden cardiac arrest survivors

OBJECTIVE

Recent research has explored the use of continuous EEG (cEEG) monitoring for prognostication of spontaneous cardiac arrest (SCA). However, there is limited literature on the long-term (post-hospital discharge) electrographic findings among SCA survivors and their clinical correlates. Our study aims to fill this critical knowledge gap.

METHODS

We retrospectively used our EEG database to identify adults (≥18 years) with SCA history who underwent an outpatient laboratory-based EEG between 01/01/2011 and 12/31/2018. After electronic medical records (EMR) review, patients with epilepsy history and unclear/poorly documented SCA history were excluded. Outpatient EEGs were reviewed by authors. Acute EEG findings were extracted from the EEG database and EMR. In addition, we extracted data on acute and long-term neuroimaging findings (CT/MRI), post-SCA seizures, and anti-seizure medications (ASM) status. Descriptive analysis and Fisher's exact test were performed.

RESULTS

We included 32 SCA survivors (50% women; mean age = 52.1 ± 13.6 years) in the study. During a median clinical follow-up of 28.2 months, 3 patients suffered only clinical seizures, 3 only chronic post-hypoxic myoclonus, and 5 had both [11 (34.4%) in total]. Interictal epileptiform discharges (IEDs) were noted in one-third of the patients, which localized to vertex and frontocentral regions in all but one patient. Five (15.6%) of them did not suffer a clinical seizure despite the presence of EAs. Patients who developed epilepsy were significantly more likely to have abnormal neuroimaging findings [10/11 (90.9%)] during the follow-up compared to the rest of the patients [OR = 25 (95% CI 2.6->100, P = .002)]. Half of the study cohort was taking ASM at the last follow-up.

SIGNIFICANCE

Our small study reveals a signature location of IEDs in SCA survivors. Neuroimaging abnormalities seem to be a better indicator of epilepsy development, while EEG may reveal markers of potential epileptogenicity in the absence of clinical seizures. Future, larger studies are needed to confirm our findings.

Continuous electroencephalography characteristics and acute symptomatic seizures in COVID-19 patients

OBJECTIVE

As concerns regarding neurological manifestations in COVID-19 (coronavirus disease 2019) patients increase, limited data exists on continuous electroencephalography (cEEG) findings in these patients. We present a retrospective cohort study of cEEG monitoring in COVID-19 patients to better explore this knowledge gap.

METHODS

Among 22 COVID-19 patients, 19 underwent cEEGs, and 3 underwent routine EEGs (<1 h). Demographic and clinical variables, including comorbid conditions, discharge disposition, survival and cEEG findings, were collected.

RESULTS

cEEG was performed for evaluation of altered mental status (n = 17) or seizure-like events (n = 5). Five patients, including 2 with epilepsy, had epileptiform abnormalities on cEEG. Two patients had electrographic seizures without a prior epilepsy history. There were no acute neuroimaging findings. Periodic discharges were noted in one-third of patients and encephalopathic EEG findings were not associated with IV anesthetic use.

CONCLUSIONS

Interictal epileptiform abnormalities in the absence of prior epilepsy history were rare. However, the discovery of asymptomatic seizures in two of twenty-two patients was higher than previously reported and is therefore of concern.

SIGNIFICANCE

cEEG monitoring in COVID-19 patients may aid in better understanding an epileptogenic potential of SARS-CoV2 infection. Nevertheless, larger studies utilizing cEEG are required to better examine acute epileptic risk in COVID-19 patients.

Abstract TP457: Intraventricular and Intravenous Milrinone for Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage

Introduction: Cerebral vasospasm (CVS) is a complication of aneurysmal subarachnoid hemorrhage (aSAH). Intraventricular milrinone (IVtM) and intravenous milrinone (IVM) have been studied for treatment of CVS. We aimed to determine the effect of milrinone therapy on clinical and transcranial Doppler (TCD) measures of CVS.

Methods: We performed a retrospective analysis of patients with aSAH treated with IVtM at a single tertiary center between 2016 and 2018. Patients were treated with IVtM if they had symptomatic CVS or TCD suggestive of critical CVS that persisted despite blood pressure augmentation or endovascular therapies. Nimodipine was given as standard of care. A subset of patients were also treated with IVM, which was dosed in a standard fashion based on Montreal Neurological Institute protocol. We collected demographic data, TCD mean flow velocity and pulsatility index, angiographic data, as well as utilization and frequency of IVtM and IVM.

Results: Twenty-eight patients in our cohort had modified Fisher grade 4 (57%) or grade 3 (25%) and median Hunt-Hess score of 3 (IQR 2, 4). Twenty-one of 28 patients were treated with IVtM+IVM. Seven (25%) who received IVtM alone had no significant improvement in TCD velocities or reduction in symptomatic CVS (p=0.611). Patients received between 1 and 30 doses of IVtM. There was no significant improvement with time or with number of IVtM doses IVtM. There was also no significant improvement in TCD velocities of CVS patients nor reduction in symptomatic CVS with IVtM+IVM (p=0.69). The number of IVtM doses correlated with an increased discharge mRS (p=0.05). There were no direct complications due to IVtM or IVM.

Conclusion: Neither IVtM+IVM nor IVtM alone appear to be effective treatment of CVS in aSAH. Our data represent one of the first case series reporting IVtM and IVtM+IVM utilization for the treatment of CVS.

Inadvertent Central Arterial Catheterization: An Unusual Cause of Ischemic Stroke

Central venous catheter (CVC) insertion is extensively utilized in Intensive Care Units for evaluation of hemodynamic status, administration of intravenous drugs, and for providing nutritional support in critically ill patients. Unfortunately, CVC use is associated with complications including lung injury, bleeding, infection, and thrombosis. We present a patient with an acute ischemic stroke from an inadvertently placed CVC into the right common carotid artery. A 57-year-old male presented to our institution for left hemiplegia and seizures 2 days after a CVC was placed. He was found to have a right frontal ischemic stroke on computed tomography (CT). CT angiography noted that the catheter was arterial and had a thrombosis around it. He was started on a low-dose heparin infusion. A combination of cardiothoracic surgery and interventional cardiology was required to safely remove the catheter. Central arterial catheterization is an unusual cause for acute ischemic stroke and presents management challenges.

Patient-reported outcomes across cerebrovascular event types: More similar than different

OBJECTIVES

To compare the degrees to which 8 domains of health are affected across types of cerebrovascular events and to identify factors associated with domain scores in different event types.

METHODS

This was an observational cohort study of 2,181 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or TIA in a cerebrovascular clinic from February 17, 2015, to June 2, 2017 who completed Quality of Life in Neurologic Disorders executive function and the following Patient-Reported Outcomes Measurement Information System scales as part of routine care: physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance.

RESULTS

All health domains were affected to similar degrees in patients with ICH, SAH, and ischemic stroke after adjustment for disability and other clinical factors, whereas patients with TIA had worse adjusted scores for 5 of the 8 domains of health. Female sex, younger age, lower income, and event <90 days were associated with worse scores in multiple domains. Factors associated with health domain scores were similar for all cerebrovascular events. Most affected domains for all were physical function, satisfaction with social roles, and executive function.

CONCLUSIONS

The subtype of stroke (ischemic stroke, ICH, and SAH) had similar effects in multiple health domains, while patients with TIA had worse adjusted outcomes, suggesting that the mechanisms for outcomes after TIA may differ from those of other cerebrovascular events. The most affected domains across all event types were physical function, satisfaction with social roles, and executive function, highlighting the need to develop effective interventions to improve these health domains in survivors of these cerebrovascular events.

New onset epilepsy among patients with periodic discharges on continuous electroencephalographic monitoring

OBJECTIVE

To evaluate the incidence of new onset epilepsy and associated risk factors in patients with periodic patterns on continuous electroencephalography (cEEG) during critical illness.

METHODS

The local cEEG database and then medical records were reviewed from January 1, 2013 to June 30, 2013 to find adult patients with no history of epilepsy who had periodic discharges-either lateralized (LPDs) or generalized (GPDs)-or nonperiodic/nonepileptogenic (NP/NE) findings on cEEG and ≥3 months of clinical follow-up. Clinical seizure after discharge was the primary outcome. Chi-square test, Kruskal-Wallis test, and Cox proportional hazards models were used for statistical analysis.

RESULTS

A total of 195 patients (median age = 67.8 years) were included. There were 53 (27%), 73 (37%), and 69 (35%) patients with LPDs, GPDs, and NP/NE findings on cEEG, respectively. These three groups did not differ by demographic or clinical variables. A total of 29 (15%) patients (LPDs = 20 [38%], GPDs = 4 [6%], and NP/NE = 5 [7%]) developed epilepsy during a median follow-up of 32.1 (95% confidence interval [CI] = 13.2-42.8) months. The hazard ratio for epilepsy development among LPD patients was 7.7 (95% CI = 2.9-20.7) times compared to the NP/NE group, and the risk further increased to 11.4 (95% CI = 4-31.4) times if they also had electrographic seizures. This association remained significant despite adjusting for each covariate at a time.

SIGNIFICANCE

Patients with LPDs on cEEG during critical illness are at least seven times more likely to develop epilepsy compared to patients with NP/NE findings. This risk is further increased if patients with LPDs have electrographic seizures. In comparison, the presence of GPDs does not seem to impact the risk for developing epilepsy. cEEG findings at the time of acute insult have potential to serve as prognostic biomarkers for epilepsy development.

Republished: Paradoxical cerebral air embolism causing large vessel occlusion treated with endovascular aspiration

Cerebral air embolism is a dreaded complication of invasive medical procedures. The mainstay of therapy for patients with cerebral air embolism has been hyperbaric oxygen therapy, high flow oxygen therapy, and anticonvulsants. We present a novel therapeutic approach for treatment of cerebral air embolism causing large vessel occlusion, using endovascular aspiration. Our patient developed a cerebral air embolism following sclerotherapy for varicose veins. This caused near total occlusion of the superior division of the M2 segment of the right middle cerebral artery. Symptoms included unilateral paralysis, unintelligible speech, and hemianopia; National Institutes of Health Stroke Scale (NIHSS) on presentation was 16. The air embolism was treated using a distal aspiration technique. Angiography following aspiration showed Thrombolysis in Cerebral Infarction 2B reperfusion. Following aspiration, the patient was re-examined; NIHSS at that time was 4. At 1 month follow-up, the modified Rankin Scale score was 1 and NIHSS was 1. Treatment of cerebral air embolism is discussed.

Paradoxical cerebral air embolism causing large vessel occlusion treated with endovascular aspiration

Cerebral air embolism is a dreaded complication of invasive medical procedures. The mainstay of therapy for patients with cerebral air embolism has been hyperbaric oxygen therapy, high flow oxygen therapy, and anticonvulsants. We present a novel therapeutic approach for treatment of cerebral air embolism causing large vessel occlusion, using endovascular aspiration. Our patient developed a cerebral air embolism following sclerotherapy for varicose veins. This caused near total occlusion of the superior division of the M2 segment of the right middle cerebral artery. Symptoms included unilateral paralysis, unintelligible speech, and hemianopia; National Institutes of Health Stroke Scale (NIHSS) on presentation was 16. The air embolism was treated using a distal aspiration technique. Angiography following aspiration showed Thrombolysis in Cerebral Infarction 2B reperfusion. Following aspiration, the patient was re-examined; NIHSS at that time was 4. At 1 month follow-up, the modified Rankin Scale score was 1 and NIHSS was 1. Treatment of cerebral air embolism is discussed.

Renal and gastrointestinal amyloidosis in an HIV-infected injection drug user

A 30-year-old HIV-infected intravenous drug user presented with sepsis, acute renal failure, oedema, proteinuria and iron deficiency anaemia. After extensive investigation, a diagnosis of reactive systemic AA (amyloid, serum amyloid A protein) amyloidosis was made on the basis of renal, gastric and duodenal biopsies.

Abstract 3097: Acute In-hospital Stroke: How Do We Do Compared To Strokes In The Emergency Department?

Introduction: Intravenous tissue plasminogen activator (IV tPA) has been approved for treating strokes up to 3 hours after onset of symptoms and may be beneficial up to 4.5 hours in patients who qualify. Additionally, neuro-intervention, i.e., intra-arterial thrombolysis or thrombectomy, is also an approved treatment option. Population studies show that 6% receive IV tPA within 3 hours of stroke onset. However, in-hospital strokes present challenges to treating within an adequate time. We present here our experience with in-hospital strokes, treatments, and identifiable delays in treatments.

Methods: Single, tertiary center retrospective study of 55 in-hospital strokes over a one-year period from January 2009 to January 2010, and strokes in the Emergency Department over 6 month period from January 2010 to June 2010.

Results: Twenty-nine in-hospital strokes were evaluated within 3 hours of symptoms onset. Two (6.9%) received IV tPA, and four (13.8%) received neuro-intervention (either intra-arterial thrombolysis or thrombectomy). None of the patients who presented greater than 3 hours after symptom onset was treated with any treatment (n=28). When compared to patients who present to the ED within 3 hours, in-hospital strokes were less likely to get IV tPA (6.9% vs. 20.8%), and they were more likely to receive neuro-intervention (13.8% vs. 10.3%). Neuro-intervention was performed on 9.09% of all in-hospital strokes (1 of 5 presented beyond the 3 hour time window). For in-hospital strokes that receive any treatment within 3 hours, the average time to neurology evaluation, to CT, and to treatment are 35 min, 68 min, and 237 min, respectively. For strokes in the Ed, the average time to evaluation, to CT, and to treatment are 90 min, 28 min, and 66 min respectively. The delay for in-hospital strokes is in obtaining the CT and initiating the treatment.

Discussion: In-hospital stroke patients wait longer than their ED counterparts to be taken to CT and to receive stroke treatment. They are also less likely to receive IV tPA, and more likely to receive neuro-intervention. The longer time to neuro-imaging and thrombolytic treatment may reflect the fact that patients suffering in-hospital strokes have more complex medical co-morbidities that must be taken account during the evaluation and administration of thrombolytic therapy.

Abstract 91: Nurses Activate Inpatient Stroke Alerts Faster than Physicians and are Equally Competent at Identifying Stroke Patients versus Stroke Mimics

Introduction: In-hospital “stroke alerts” are typically activated when a patient’s neurological status acutely deteriorates. Acute inpatient strokes represent an excellent potential opportunity for definitive treatment, but over triaging causing false alarms was a challenge at our institution, especially in the cardiology/CT surgery units, where many stroke mimic patients were being seen. Our stroke nurse, stroke coordinator, and stroke team physicians designed and implemented a formal collaborative educational initiative to improve quality and timeliness of stroke pager calls.

Hypothesis: Non- neurological nurses educated to recognize stroke signs and symptoms who activate the stroke team will identify at least as great a proportion of true stroke patients as physicians.

Methods: We retrospectively analyzed prospectively collected inpatient stroke team calls on 93 inpatients over one year’s time. The person (physician versus nurse) calling the stroke alert was identified via shared electronic medical record review. We compared the proportion of patients (via chi-square analysis) who after formal chart review had a true diagnosis of stroke (versus mimic). Neurological floor and neuro-ICU patients were excluded.

Results: Nurses initiated 59/93 stroke team calls (63%) during the study period. Overall, 59% (37/59) of nurse- activated calls were for patients whom ultimately were determined to have had a true stroke as compared to 63% of physician-activated calls (20/34); p=0.71; 60% of stroke alerts came from the cardiology/CT surgery nursing units, and the accuracy of nurses on these units was 67% as compared to 53% for other non- neurological nursing units. (p=.323). Nurses activated the stroke team faster (median 2 hours [25 th , 75 th %ile 0.5hr, 6 hrs]) than physicians (median 4.9hrs [25 th , 75 th %ile 1.3, 21.3 hrs]), p=.0096 {Wilcoxon Rank Sum}.

Conclusions: Non- neurological nurses educated on stroke recognition and stroke team activation are as accurate at identifying inpatient acute stroke patients as physicians, and do so more than twice as fast on average as physicians. Intensive, focused, collaborative education of nursing staff in high-risk for inpatient stroke units, who typically more frequently assess patients than physicians, may via rapid and accurate identification improve inpatient stroke outcomes.

HIV opt-out increases HIV testing in low-risk patients

We audited the effect of introducing HIV opt-out in a genitourinary medicine clinic in central London, UK. We found that opt-out increased the rate at which HIV testing was offered to low-risk patients and that more tests were done.

Effect of material deprivation on Epstein-Barr virus infection in Hodgkin's disease in the West Midlands

We have used Townsend scores from postcode data to compare levels of material deprivation and Epstein-Barr virus (EBV)-positivity for 223 patients diagnosed with Hodgkin's disease (HD) in the period 1981-1997. The presence of EBV in HD tumours was determined using in situ hybridization to target the abundantly expressed EBV early RNAs. EBV was detected in the malignant Hodgkin and Reed-Sternberg cells in 47/223 HD cases (21%). There was found to be a tendency for higher Townsend scores (indicative of higher levels of material deprivation) in EBV-positive HD patients, but this association was not statistically significant. When various subgroups of patients from the study were examined separately the indication of higher Townsend scores in EBV-positive patients was found to be more marked for patients with mixed cellularity disease (P = 0.09) and for females (P = 0.03). The results of this study suggest that differences in the level of material deprivation are important in determining the likelihood of EBV-positive HD in the UK, particularly for certain subgroups of patients. It is not known what specific socioeconomic factors are responsible for these differences, although alterations in the timing or rate of primary EBV infection, or decline in the level of EBV-specific immunity, may be important.

The computer-based anesthetic monitors: the Duke Automatic Monitoring Equipment (DAME) system and the microDAME

From 1972 to 1983 the Duke University Department of Anesthesiology designed, built, and maintained most of its own operating room patient monitoring equipment. Construction of a new hospital facility in 1980 provided the opportunity to design and test a new computer-based system, the Duke Automatic Monitoring Equipment (DAME) System. The system consist of microcomputer-based instrumentation on monitoring carts, which communicate with a central minicomputer that allows selection of different software monitoring packages based on the needs of the patient. Multiple problems, including frequent total monitoring failures during surgery, plagued the DAME System in its first year of operation. Despite resolution of many of these problems, user acceptance was poor because of the large size and weight of the monitoring carts, the inadequate quality of displayed physiological waveforms, and inability to overcome the difficulties of the man-machine interface. Because the remaining problems could not be rectified with the existing monitoring carts, a new generation of monitors was designed. The smaller, multiprocessor microDAME was designed to be as automatic and user tolerant as possible. It would omit much of the flexibility that had proved undesirable in the DAME system. When the microDAME was nearly completed, however, departmental research in that area ceased. It remains for others to apply our experiences to further improve operating room patient monitors.

Assessment of a new visual blood glucose strip

A new double-tipped strip for home glucose monitoring without a meter is described. Comparison between values obtained with the new method by trained nursing staff and those obtained with a glucose-oxidase analyzer demonstrates close correlation between the two methods (r = +0.95, a = +22.2 mg/dl, b = +1.14). The mean concentration in 117 strip tests over an analyzer range of 5-775 mg/dl (0.3-43.0 mmol/L) was 52 mg/dl (2.9 mmol/L) greater than the analyzer estimate. Forty-seven percent of samples were read as the color block closest to the analyzer estimate. Samples in the lower glucose range tended to read one block high. The technique is faster to perform than most other visual blood glucose strip methods, and is a useful addition to the equipment available for home glucose monitoring. Modifications to the strip by the manufacturers appear to have overcome the low value over-reading error.