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Hwang DY, Kim KS, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Madzar D, Mahanes D, Mainali S, Sakowitz OW, Varelas PN, Weimar C, Westermaier T, Meixensberger J. Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage. Neurocrit Care 2024; 40:395-414. [PMID: 37923968 PMCID: PMC10959839 DOI: 10.1007/s12028-023-01854-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The objective of this document is to provide recommendations on the formal reliability of major clinical predictors often associated with intracerebral hemorrhage (ICH) neuroprognostication. METHODS A narrative systematic review was completed using the Grading of Recommendations Assessment, Development, and Evaluation methodology and the Population, Intervention, Comparator, Outcome, Timing, Setting questions. Predictors, which included both individual clinical variables and prediction models, were selected based on clinical relevance and attention in the literature. Following construction of the evidence profile and summary of findings, recommendations were based on Grading of Recommendations Assessment, Development, and Evaluation criteria. Good practice statements addressed essential principles of neuroprognostication that could not be framed in the Population, Intervention, Comparator, Outcome, Timing, Setting format. RESULTS Six candidate clinical variables and two clinical grading scales (the original ICH score and maximally treated ICH score) were selected for recommendation creation. A total of 347 articles out of 10,751 articles screened met our eligibility criteria. Consensus statements of good practice included deferring neuroprognostication-aside from the most clinically devastated patients-for at least the first 48-72 h of intensive care unit admission; understanding what outcomes would have been most valued by the patient; and counseling of patients and surrogates whose ultimate neurological recovery may occur over a variable period of time. Although many clinical variables and grading scales are associated with ICH poor outcome, no clinical variable alone or sole clinical grading scale was suggested by the panel as currently being reliable by itself for use in counseling patients with ICH and their surrogates, regarding functional outcome at 3 months and beyond or 30-day mortality. CONCLUSIONS These guidelines provide recommendations on the formal reliability of predictors of poor outcome in the context of counseling patients with ICH and surrogates and suggest broad principles of neuroprognostication. Clinicians formulating their judgments of prognosis for patients with ICH should avoid anchoring bias based solely on any one clinical variable or published clinical grading scale.
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599-7025, USA.
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Susanne Muehlschlegel
- Division of Neurosciences Critical Care, Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | - Christian Weimar
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper-Kliniken Dachau, University of Wuerzburg, Würzburg, Germany
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Mahanes D, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mainali S, Meixensberger J, Varelas PN, Weimar C, Westermaier T, Sakowitz OW. Guidelines for neuroprognostication in adults with traumatic spinal cord injury. Neurocrit Care 2024; 40:415-437. [PMID: 37957419 PMCID: PMC10959804 DOI: 10.1007/s12028-023-01845-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/17/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (tSCI) impacts patients and their families acutely and often for the long term. The ability of clinicians to share prognostic information about mortality and functional outcomes allows patients and their surrogates to engage in decision-making and plan for the future. These guidelines provide recommendations on the reliability of acute-phase clinical predictors to inform neuroprognostication and guide clinicians in counseling adult patients with tSCI or their surrogates. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development, and Evaluation methodology. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and presence of an appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Timing/Setting question was framed as "When counseling patients or surrogates of critically ill patients with traumatic spinal cord injury, should < predictor, with time of assessment if appropriate > be considered a reliable predictor of < outcome, with time frame of assessment >?" Additional full-text screening criteria were used to exclude small and lower quality studies. Following construction of an evidence profile and summary of findings, recommendations were based on four Grading of Recommendations Assessment, Development, and Evaluation criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. Good practice recommendations addressed essential principles of neuroprognostication that could not be framed in the Population/Intervention/Comparator/Outcome/Timing/Setting format. Throughout the guideline development process, an individual living with tSCI provided perspective on patient-centered priorities. RESULTS Six candidate clinical variables and one prediction model were selected. Out of 11,132 articles screened, 369 met inclusion criteria for full-text review and 35 articles met eligibility criteria to guide recommendations. We recommend pathologic findings on magnetic resonance imaging, neurological level of injury, and severity of injury as moderately reliable predictors of American Spinal Cord Injury Impairment Scale improvement and the Dutch Clinical Prediction Rule as a moderately reliable prediction model of independent ambulation at 1 year after injury. No other reliable or moderately reliable predictors of mortality or functional outcome were identified. Good practice recommendations include considering the complete clinical condition as opposed to a single variable and communicating the challenges of likely functional deficits as well as potential for improvement and for long-term quality of life with SCI-related deficits to patients and surrogates. CONCLUSIONS These guidelines provide recommendations about the reliability of acute-phase predictors of mortality, functional outcome, American Spinal Injury Association Impairment Scale grade conversion, and recovery of independent ambulation for consideration when counseling patients with tSCI or their surrogates and suggest broad principles of neuroprognostication in this context.
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Affiliation(s)
- Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, University of Virginia, Charlottesville, VA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Christian Weimar
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Clinic Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper-Klinikum Dachau, Dachau, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany.
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Muehlschlegel S, Rajajee V, Wartenberg KE, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Sakowitz OW, Varelas PN, Weimar C, Westermaier T. Guidelines for Neuroprognostication in Critically Ill Adults with Moderate-Severe Traumatic Brain Injury. Neurocrit Care 2024; 40:448-476. [PMID: 38366277 PMCID: PMC10959796 DOI: 10.1007/s12028-023-01902-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Moderate-severe traumatic brain injury (msTBI) carries high morbidity and mortality worldwide. Accurate neuroprognostication is essential in guiding clinical decisions, including patient triage and transition to comfort measures. Here we provide recommendations regarding the reliability of major clinical predictors and prediction models commonly used in msTBI neuroprognostication, guiding clinicians in counseling surrogate decision-makers. METHODS Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we conducted a systematic narrative review of the most clinically relevant predictors and prediction models cited in the literature. The review involved framing specific population/intervention/comparator/outcome/timing/setting (PICOTS) questions and employing stringent full-text screening criteria to examine the literature, focusing on four GRADE criteria: quality of evidence, desirability of outcomes, values and preferences, and resource use. Moreover, good practice recommendations addressing the key principles of neuroprognostication were drafted. RESULTS After screening 8125 articles, 41 met our eligibility criteria. Ten clinical variables and nine grading scales were selected. Many articles varied in defining "poor" functional outcomes. For consistency, we treated "poor" as "unfavorable". Although many clinical variables are associated with poor outcome in msTBI, only the presence of bilateral pupillary nonreactivity on admission, conditional on accurate assessment without confounding from medications or injuries, was deemed moderately reliable for counseling surrogates regarding 6-month functional outcomes or in-hospital mortality. In terms of prediction models, the Corticosteroid Randomization After Significant Head Injury (CRASH)-basic, CRASH-CT (CRASH-basic extended by computed tomography features), International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT)-core, IMPACT-extended, and IMPACT-lab models were recommended as moderately reliable in predicting 14-day to 6-month mortality and functional outcomes at 6 months and beyond. When using "moderately reliable" predictors or prediction models, the clinician must acknowledge "substantial" uncertainty in the prognosis. CONCLUSIONS These guidelines provide recommendations to clinicians on the formal reliability of individual predictors and prediction models of poor outcome when counseling surrogates of patients with msTBI and suggest broad principles of neuroprognostication.
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Affiliation(s)
- Susanne Muehlschlegel
- Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Saint Luke's Health System, Kansas City, MO, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper Klinikum Dachau, Dachau, Germany.
- Faculty of Medicine, University of Würzburg, Würzburg, Germany.
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Busl KM, Fried H, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Sakowitz OW, Varelas PN, Westermaier T, Weimar C. Author Correction: Guidelines for Neuroprognostication in Adults with Guillain-Barré Syndrome. Neurocrit Care 2023; 39:752. [PMID: 37726550 PMCID: PMC10689509 DOI: 10.1007/s12028-023-01830-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Affiliation(s)
- Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | | | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | | | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen and BDH-Clinic Elzach, Essen, Germany.
- BDH-Clinic Elzach, Elzach, Germany.
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5
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Rajajee V, Muehlschlegel S, Wartenberg KE, Alexander SA, Busl KM, Chou SHY, Creutzfeldt CJ, Fontaine GV, Fried H, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Montellano F, Sakowitz OW, Weimar C, Westermaier T, Varelas PN. Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest. Neurocrit Care 2023; 38:533-563. [PMID: 36949360 PMCID: PMC10241762 DOI: 10.1007/s12028-023-01688-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: "When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?" Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format. RESULTS Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors. CONCLUSIONS These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurology and Neurosurgery, 3552 Taubman Health Care Center, SPC 5338, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5338, USA.
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sherry H Y Chou
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keri S Kim
- Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Clinic Elzach, Elzach, Germany
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Oishi T, Triplett JD, Laughlin RS, Hocker SE, Berini SE, Hoffman EM. Short-Acting Neuromuscular Blockade Improves Inter-rater Reliability of Median Somatosensory Evoked Potentials in Post-cardiac arrest Prognostication. Neurocrit Care 2023; 38:600-611. [PMID: 36123569 DOI: 10.1007/s12028-022-01601-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/29/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although median nerve somatosensory evoked potentials are routinely used for prognostication in comatose cardiac arrest survivors, myogenic artifact can reduce inter-rater reliability, leading to unreliable or inaccurate results. To minimize this risk, we determined the benefit of neuromuscular blockade agents in improving the inter-rater reliability and signal-to-noise ratio of SSEPs in the context of prognostication. METHODS Thirty comatose survivors of cardiac arrest were enrolled in the study, following the request from an intensivist to complete an SSEP for prognostication. Right and left median nerve SSEPs were obtained from each patient, before and after administration of an NMB agent. Clinical histories and outcomes were retrospectively reviewed. The SSEP recordings before and after NMB were randomized and reviewed by five blinded raters, who assessed the latency and amplitude of cortical and noncortical potentials (vs. absence of response) as well as the diagnostic quality of cortical recordings. The inter-rater reliability of SSEP interpretation before and after NMB was compared via Fleiss' κ score. RESULTS Following NMB administration, Fleiss' κ score for cortical SSEP interpretation significantly improved from 0.37 to 0.60, corresponding to greater agreement among raters. The raters were also less likely to report the cortical recordings as nondiagnostic following NMB (40.7% nondiagnostic SSEPs pre-NMB; 17% post-NMB). The SNR significantly improved following NMB, especially when the pre-NMB SNR was low (< 10 dB). Across the raters, there were three patients whose SSEP interpretation changed from bilaterally absent to bilaterally present after NMB was administered (potential false positives without NMB). CONCLUSIONS NMB significantly improves the inter-rater reliability and SNR of median SSEPs for prognostication among comatose cardiac arrest survivors. To ensure the most reliable prognostic information in comatose post-cardiac arrest survivors, pharmacologic paralysis should be consistently used before recording SSEPs.
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Affiliation(s)
- Tatsuya Oishi
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA.
| | - James D Triplett
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
- Department of Neurology, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Ruple S Laughlin
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Sarah E Berini
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Ernest M Hoffman
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
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7
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Busl KM, Fried H, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Sakowitz OW, Varelas PN, Westermaier T, Weimar C. Guidelines for Neuroprognostication in Adults with Guillain-Barré Syndrome. Neurocrit Care 2023; 38:564-583. [PMID: 36964442 PMCID: PMC10241707 DOI: 10.1007/s12028-023-01707-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/23/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Guillain-Barré syndrome (GBS) often carries a favorable prognosis. Of adult patients with GBS, 10-30% require mechanical ventilation during the acute phase of the disease. After the acute phase, the focus shifts to restoration of motor strength, ambulation, and neurological function, with variable speed and degree of recovery. The objective of these guidelines is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling adult patients with GBS and/or their surrogates. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and presence of appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Time frame/Setting (PICOTS) question was framed as follows: "When counseling patients or surrogates of critically ill patients with Guillain-Barré syndrome, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of [outcome, with time frame of assessment]?" Additional full-text screening criteria were used to exclude small and lower quality studies. Following construction of an evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format. RESULTS Eight candidate clinical variables and six prediction models were selected. A total of 45 articles met our eligibility criteria to guide recommendations. We recommend bulbar weakness (the degree of motor weakness at disease nadir) and the Erasmus GBS Respiratory Insufficiency Score as moderately reliable for prediction of the need for mechanical ventilation. The Erasmus GBS Outcome Score (EGOS) and modified EGOS were identified as moderately reliable predictors of independent ambulation at 3 months and beyond. Good practice recommendations include consideration of both acute and recovery phases of the disease during prognostication, discussion of the possible need for mechanical ventilation and enteral nutrition during counseling, and consideration of the complete clinical condition as opposed to a single variable during prognostication. CONCLUSIONS These guidelines provide recommendations on the reliability of predictors of the need for mechanical ventilation, poor functional outcome, and independent ambulation following GBS in the context of counseling patients and/or surrogates and suggest broad principles of neuroprognostication. Few predictors were considered moderately reliable based on the available body of evidence, and higher quality data are needed.
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Affiliation(s)
- Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | | | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | | | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen and BDH-Clinic Elzach, Essen, Germany.
- BDH-Clinic Elzach, Elzach, Germany.
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8
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Busl KM, Fried H, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Sakowitz OW, Varelas PN, Westermaier T, Weimar C. Correction to: Guidelines for Neuroprognostication in Adults with Guillain-Barré Syndrome. Neurocrit Care 2023:10.1007/s12028-023-01726-0. [PMID: 37100978 DOI: 10.1007/s12028-023-01726-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Affiliation(s)
- Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | | | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | | | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen and BDH-Clinic Elzach, ,Essen, Germany.
- BDH-Clinic Elzach, Elzach, Germany.
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9
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Osman GM, Hocker SE. Status Epilepticus in Older Adults: Diagnostic and Treatment Considerations. Drugs Aging 2023; 40:91-103. [PMID: 36745320 DOI: 10.1007/s40266-022-00998-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 02/07/2023]
Abstract
Status epilepticus (SE) is one of the leading life-threatening neurological emergencies in the elderly population, with significant morbidity and mortality. SE presents unique diagnostic and therapeutic challenges in the older population given overlap with other causes of encephalopathy, complicating diagnosis, and the common occurrence of multiple comorbid diseases complicates treatment. First-line therapy involves the use of rescue benzodiazepine in the form of intravenous lorazepam or diazepam, intramuscular or intranasal midazolam and rectal diazepam. Second-line therapies include parenteral levetiracetam, fosphenytoin, valproate and lacosamide, and underlying comorbidities guide the choice of appropriate medication, while third-line therapies may be influenced by the patient's code status as well as the cause and type of SE. The standard of care for convulsive SE is treatment with an intravenous anesthetic, including midazolam, propofol, ketamine and pentobarbital. There is currently limited evidence guiding appropriate therapy in patients failing third-line therapies. Adjunctive strategies may include immunomodulatory treatments, non-pharmacological strategies such as ketogenic diet, neuromodulation therapies and surgery in select cases. Surrogate decision makers should be updated early and often in refractory episodes of SE and informed of the high morbidity and mortality associated with the disease as well as the high probability of subsequent epilepsy among survivors.
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Affiliation(s)
- Gamaleldin M Osman
- Department of Neurology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN, 55905, USA.
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10
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Chiu WT, Campozano V, Schiefecker A, Rodriguez DR, Ferreira D, Headlee A, Zeidan S, Grinea A, Huang YH, Doyle K, Shen Q, Gómez D, Hocker SE, Rohaut B, Sonneville R, Hong CT, Demeret S, Kurtz P, Maldonado N, Helbok R, Fernandez T, Claassen J. Management of Refractory Status Epilepticus: An International Cohort Study (MORSE CODe) Analysis of Patients Managed in the ICU. Neurology 2022; 99:e1191-e1201. [PMID: 35918156 PMCID: PMC9536742 DOI: 10.1212/wnl.0000000000200818] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/19/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Status epilepticus that continues after the initial benzodiazepine and a second anticonvulsant medication is known as refractory status epilepticus (RSE). Management is highly variable because adequately powered clinical trials are missing. We aimed to determine whether propofol and midazolam were equally effective in controlling RSE in the intensive care unit, focusing on management in resource-limited settings. METHODS Patients with RSE treated with midazolam or propofol between January 2015 and December 2018 were retrospectively identified among 9 centers across 4 continents from upper-middle-income economies in Latin America and high-income economies in North America, Europe, and Asia. Demographics, Status Epilepticus Severity Score, etiology, treatment details, and discharge modified Rankin Scale (mRS) were collected. The primary outcome measure was good functional outcome defined as a mRS score of 0-2 at hospital discharge. RESULTS Three hundred eighty-seven episodes of RSE (386 patients) were included, with 162 (42%) from upper-middle-income and 225 (58%) from high-income economies. Three hundred six (79%) had acute and 79 (21%) remote etiologies. Initial RSE management included midazolam in 266 (69%) and propofol in 121 episodes (31%). Seventy episodes (26%) that were initially treated with midazolam and 42 (35%) with propofol required the addition of a second anesthetic to treat RSE. Baseline characteristics and outcomes of patients treated with midazolam or propofol were similar. Breakthrough (odds ratio [OR] 1.6, 95% CI 1.3-2.0) and withdrawal seizures (OR 2.0, 95% CI 1.7-2.5) were associated with an increased number of days requiring continuous intravenous anticonvulsant medications (cIV-ACMs). Prolonged EEG monitoring was associated with fewer days of cIV-ACMs (1-24 hours OR 0.5, 95% CI 0.2-0.9, and >24 hours OR 0.7, 95% CI 0.5-1.0; reference EEG <1 hour). This association was seen in both, high-income and upper-middle-income economies, but was particularly prominent in high-income countries. One hundred ten patients (28%) were dead, and 80 (21%) had good functional outcomes at hospital discharge. DISCUSSION Outcomes of patients with RSE managed in the intensive care unit with propofol or midazolam infusions are comparable. Prolonged EEG monitoring may allow physicians to decrease the duration of anesthetic infusions safely, but this will depend on the implementation of RSE management protocols. Goal-directed management approaches including EEG targets may hold promise for patients with RSE. CLASSIFICATION OF EVIDENCE This study provides Class III data that propofol and midazolam are equivalently efficacious for RSE.
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Affiliation(s)
- Wei-Ting Chiu
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Vanessa Campozano
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Alois Schiefecker
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Dannys Rivero Rodriguez
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Daniel Ferreira
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Amy Headlee
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Sinead Zeidan
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Alexandra Grinea
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Yao-Hsien Huang
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Kevin Doyle
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Qi Shen
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Diana Gómez
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Sara E Hocker
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Benjamin Rohaut
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Romain Sonneville
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Chien-Tai Hong
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Sophie Demeret
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Pedro Kurtz
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Nelson Maldonado
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Raimund Helbok
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Telmo Fernandez
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Jan Claassen
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France.
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11
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Wallace LA, Hocker SE, Dubrock H, Bauer P. Diabetic ketoacidosis, cerebral venous sinus thrombosis and fulminant cerebral oedema in COVID-19 infection complicated by Klebsiella pneumoniae infection. BMJ Case Rep 2022; 15:15/4/e248046. [PMID: 35379681 PMCID: PMC8981356 DOI: 10.1136/bcr-2021-248046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We present an unusual case of a woman in her 30s who was admitted for diabetic ketoacidosis (DKA) in the setting of newly diagnosed but late COVID-19 infection with associated Klebsiella pneumoniae infection. Her altered mental status, out of proportion with her metabolic decompensation, revealed a superimposed cerebral venous sinus thrombosis (CVST) with fulminant cerebral oedema and ultimately brain death. This unusual and fulminant case of cerebral oedema in the setting of COVID-19 infection with bacterial infection, DKA and CVST was the perfect storm with multiple interwoven factors. It offered diagnostic and treatment challenges with an unfortunate outcome. This unique case is a reminder that it is important to consider a broad neurological differential in patients with COVID-19 with unexplained neurological manifestations, which may require specific neurointensive care management.
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Affiliation(s)
- Lindsey A Wallace
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Philippe Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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12
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Haddad NA, Schreier DJ, Fugate JE, Gajic O, Hocker SE, Ice CJ, Leung SB, Mara KC, Rabinstein AA, Rule AD, Barreto EF. Incidence and Predictive Factors Associated with Beta-Lactam Neurotoxicity in the Critically Ill: A Retrospective Cohort Study. Neurocrit Care 2022; 37:73-80. [PMID: 35137352 PMCID: PMC9288522 DOI: 10.1007/s12028-022-01442-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/04/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Beta-lactam neurotoxicity is a relatively uncommon yet clinically significant adverse effect in critically ill patients. This study sought to define the incidence of neurotoxicity, derive a prediction model for beta-lactam neurotoxicity, and then validate the model in an independent cohort of critically ill adults. METHODS This retrospective cohort study evaluated critically ill patients treated with ≥ 48 h of cefepime, piperacillin/tazobactam, or meropenem. Two separate cohorts were created: a derivation cohort and a validation cohort. Patients were screened for beta-lactam neurotoxicity by using search terms and diagnosis codes, followed by clinical adjudication using a standardized adverse event scoring tool. Multivariable regression models and least absolute shrinkage and selection operator were used to identify surrogates for neurotoxicity and develop a multivariable prediction model. RESULTS The overall incidence of beta-lactam neurotoxicity was 2.6% (n/N = 34/1323) in the derivation cohort and 2.1% in the validation cohort (n/N = 16/767). The final multivariable neurotoxicity assessment tool included weight, Charlson comorbidity score, age, and estimated creatinine clearance as predictors of neurotoxicity. Incidence of neurotoxicity reached 4% in those with a body mass index more than 30 kg/m2. Use of the candidate variables in the neurotoxicity assessment tool suggested that a score more than 35 would identify a patient at high risk for neurotoxicity with 75% sensitivity and 54% specificity. CONCLUSIONS In this single center cohort of critically ill patients, beta-lactam neurotoxicity was demonstrated less frequently than previously reported. We identified obesity as a novel risk factor for the development of neurotoxicity. The prediction model needs to be further refined before it can be used in clinical practice as a tool to avoid drug-related harm.
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Affiliation(s)
- Natalie A Haddad
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - Diana J Schreier
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | | | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sara E Hocker
- Division of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Calvin J Ice
- Department of Pharmacy, Spectrum Health, Grand Rapids, MI, USA
| | - Sarah B Leung
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - Kristin C Mara
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA.
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13
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Smith KM, Rydberg CH, Hocker SE. Thalamic venous infarction from trauma mimicking a glioma. Clin Imaging 2020; 73:23-25. [PMID: 33296768 DOI: 10.1016/j.clinimag.2020.11.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/09/2020] [Accepted: 11/21/2020] [Indexed: 11/30/2022]
Abstract
Traumatic brain injuries (TBI) are commonly associated with motor vehicle accidents. Neuroimaging plays a crucial role in the initial management of TBIs. We present a case of a TBI related to a motor vehicle accident in an 18-year-old woman. Initial brain imaging revealed significant traumatic injuries and an enhancing mass, without restricted diffusion, in the thalamus favored to be a thalamic glioma. Subsequent imaging revealed resolution of enhancement of the thalamic lesion and reduction in size. On review of the original imaging, it was determined that the thalamic lesion was related to a tear and partial thrombosis of a large thalamic vein resulting in infarction and hemorrhage.
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Affiliation(s)
- Kelsey M Smith
- Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN 55905, United States of America.
| | - Charlotte H Rydberg
- Mayo Clinic, Department of Radiology, 200 1st St. SW, Rochester, MN 55905, United States of America.
| | - Sara E Hocker
- Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN 55905, United States of America.
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14
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Affiliation(s)
- Ali Daneshmand
- Mayo Clinic, Rochester, Minnesota (A.D., G.G., S.M., A.Z., E.F.W., S.E.H.)
| | - Gaurav Goyal
- Mayo Clinic, Rochester, Minnesota (A.D., G.G., S.M., A.Z., E.F.W., S.E.H.)
| | - Svetomir Markovic
- Mayo Clinic, Rochester, Minnesota (A.D., G.G., S.M., A.Z., E.F.W., S.E.H.)
| | | | - Eelco F M Wijdicks
- Mayo Clinic, Rochester, Minnesota (A.D., G.G., S.M., A.Z., E.F.W., S.E.H.)
| | - Sara E Hocker
- Mayo Clinic, Rochester, Minnesota (A.D., G.G., S.M., A.Z., E.F.W., S.E.H.)
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15
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Gofton TE, Wong N, Hirsch LJ, Hocker SE. Communication Challenges: A Spotlight on New-Onset Refractory Status Epilepticus. Mayo Clin Proc 2019; 94:857-863. [PMID: 30935709 DOI: 10.1016/j.mayocp.2018.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 11/04/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
Abstract
New-onset refractory status epilepticus (NORSE) is a rare, potentially devastating condition that occurs abruptly in previously healthy patients of any age but most commonly in children and young adults. It has an unpredictable clinical course requiring immediate, often prolonged, critical care support with multiple specialists involved and frequently results in severe life-altering sequelae or death. Communication in NORSE is challenging because its etiology in a given patient is initially unknown (and often remains so), the clinical course and outcome are unpredictable, and many health care team members are involved in the care of a patient. We address the communication challenges seen in NORSE through proactive communication on 3 levels: (1) in the shared decision-making process with the family, (2) within an individual hospital, and (3) across institutions. Intentional organizational change and enhanced information dissemination may help break down barriers to effective communication. Key initiatives for enhancing information dissemination in NORSE are (1) the identification of a most responsible physician to integrate information from subspecialties, to communicate frequently and candidly with the family, and to provide continuity of care over a prolonged period of time and (2) the early involvement of palliative care services alongside ongoing therapies with curative intent to support families and the medical team in decision making and communication.
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Affiliation(s)
- Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | | | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT
| | - Sara E Hocker
- Division of Critical Care Neurology, Department of Neurology, Mayo Clinic, Rochester, MN
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16
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Gofton TE, Gaspard N, Hocker SE, Loddenkemper T, Hirsch LJ. New onset refractory status epilepticus research: What is on the horizon? Neurology 2019; 92:802-810. [PMID: 30894443 DOI: 10.1212/wnl.0000000000007322] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/17/2019] [Indexed: 12/14/2022] Open
Abstract
New-onset refractory status epilepticus (NORSE) is a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurologic disorder, with new onset of refractory status epilepticus (RSE) that does not resolve after 2 or more rescue medications, without a clear acute or active structural, toxic, or metabolic cause. Febrile infection-related epilepsy syndrome is a subset of NORSE in which fever began at least 24 hours prior to the RSE. Both terms apply to all age groups. Until recently, NORSE was a poorly recognized entity without a consistent definition or approach to care. We review the current state of knowledge in NORSE and propose a roadmap for future collaborative research. Research investigating NORSE should prioritize the following 4 domains: (1) clinical features, etiology, and pathophysiology; (2) treatment; (3) adult and pediatric evaluation and management approaches; and (4) public advocacy, professional education, and family support. We consider international collaboration and multicenter research crucial in achieving these goals.
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Affiliation(s)
- Teneille E Gofton
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT.
| | - Nicolas Gaspard
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Sara E Hocker
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Tobias Loddenkemper
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Lawrence J Hirsch
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
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17
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Hawkes MA, Hocker SE, Leis AA. West Nile virus induces a post-infectious pro-inflammatory state that explains transformation of stable ocular myasthenia gravis to myasthenic crises. J Neurol Sci 2018; 395:1-3. [PMID: 30267806 DOI: 10.1016/j.jns.2018.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/05/2018] [Accepted: 09/12/2018] [Indexed: 10/28/2022]
Abstract
West Nile virus (WNV) infection has been reported to promote myasthenia gravis (MG) and various other diseases that have a presumed autoimmune pathogenesis. Molecular mimicry between WNV proteins and host proteins has been postulated as the major mechanism for WNV-triggered breaking of immunological self-tolerance. We present a patient with stable ocular MG and positive anti-acetylcholine receptor antibodies who progressed to myasthenic crisis after WNV neuroinvasive disease. In this case of stable autoimmune disease with proven auto-antibodies, transformation to generalized disease cannot be attributed to molecular mimicry, which requires that an immune response first be generated against an infectious agent. Rather, the evidence supports the concept of a post-infectious pro-inflammatory state that may contribute to the amplification and promotion of autoimmune disease in some WNV survivors.
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Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA
| | - Sara E Hocker
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA
| | - A Arturo Leis
- Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, MS, USA.
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18
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Osman G, Rahangdale R, Britton JW, Gilmore EJ, Haider HA, Hantus S, Herlopian A, Hocker SE, Woo Lee J, Legros B, Mendoza M, Punia V, Rampal N, Szaflarski JP, Wallace AD, Westover MB, Hirsch LJ, Gaspard N. Bilateral independent periodic discharges are associated with electrographic seizures and poor outcome: A case-control study. Clin Neurophysiol 2018; 129:2284-2289. [PMID: 30227348 DOI: 10.1016/j.clinph.2018.07.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/20/2018] [Accepted: 07/23/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine the clinical correlates bilateral independent periodic discharges (BIPDs) and their association with electrographic seizures and outcome. METHODS Retrospective case-control study of patients with BIPDs compared to patients without periodic discharges ("No PDs") and patients with lateralized periodic discharges ("LPDs"), matched for age, etiology and level of alertness. RESULTS We included 85 cases and 85 controls in each group. The most frequent etiologies of BIPDs were stroke, CNS infections, and anoxic brain injury. Acute bilateral cerebral injury was more common in the BIPDs group than in the No PDs and LPDs groups (70% vs. 37% vs. 35%). Electrographic seizures were more common with BIPDs than in the absence of PDs (45% vs. 8%), but not than with LPDs (52%). Mortality was higher in the BIPDs group (36%) than in the No PDs group (18%), with fewer patients with BIPDs achieving good outcome (moderate disability or better; 18% vs. 36%), but not than in the LPDs group (24% mortality, 26% good outcome). In multivariate analyses, BIPDs remained associated with mortality (OR: 3.0 [1.4-6.4]) and poor outcome (OR: 2.9 [1.4-6.2]). CONCLUSION BIPDs are caused by bilateral acute brain injury and are associated with a high risk of electrographic seizures and of poor outcome. SIGNIFICANCE BIPDs are uncommon but their identification in critically ill patients has potential important implications, both in terms of clinical management and prognostication.
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Affiliation(s)
- Gamaleldin Osman
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA; Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Ain Shams University, Cairo, Egypt
| | - Rahul Rahangdale
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Department of Neurology, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Emily J Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Hiba Arif Haider
- Division of Epilepsy, Department of Neurology, Emory University, Atlanta, GA, USA
| | | | - Aline Herlopian
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Legros
- Service de Neurologie et Centre de Référence pour le Traitement de l'Epilepsie Réfractaire, Université Libre de Bruxelles - Hôpital Erasme, Bruxelles, Belgium
| | - Michael Mendoza
- Division of Epilepsy, Department of Neurology, Emory University, Atlanta, GA, USA
| | - Vineet Punia
- Cleveland Clinic Epilepsy Center, Cleveland, OH, USA
| | - Nishi Rampal
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Adam D Wallace
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Nicolas Gaspard
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Service de Neurologie et Centre de Référence pour le Traitement de l'Epilepsie Réfractaire, Université Libre de Bruxelles - Hôpital Erasme, Bruxelles, Belgium.
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Hocker SE. Patient Management Problem. Continuum (Minneap Minn) 2018; 23:901-905. [PMID: 28570339 DOI: 10.1212/con.0000000000000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Hocker SE. Patient Management Problem-Preferred Responses. Continuum (Minneap Minn) 2018; 23:906-914. [PMID: 28570340 DOI: 10.1212/con.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
PURPOSE OF REVIEW Neurologic dysfunction is prevalent in patients with acute and chronic renal disease and may affect the central nervous system, peripheral nervous system, or both. Neurologic manifestations may result directly from the uremic state or as a consequence of renal replacement therapy. Early recognition of neurologic dysfunction may provide opportunities for intervention and reduced morbidity. RECENT FINDINGS Advances in the understanding of neurologic complications of renal disease and its treatments have led to more widespread recognition and earlier identification of encephalopathy syndromes such as cefepime neurotoxicity and posterior reversible encephalopathy syndrome (PRES), dramatic reductions in the incidence of dialysis disequilibrium syndrome and dialysis dementia, and improved survival in disorders such as von Hippel-Lindau disease and thrombotic thrombocytopenic purpura. SUMMARY This article summarizes the conditions that affect both the renal and the nervous systems, the effects of renal failure on the nervous system, and the neurologic complications of dialysis.
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Hanson KT, Zalewski NL, Hocker SE, Caselli RJ, Habermann EB, Thiels CA. At the Intersection of Patient Experience Data, Outcomes Research, and Practice: Analysis of HCAHPS Scores in Neurology Patients. Mayo Clin Proc Innov Qual Outcomes 2018; 2:137-147. [PMID: 30225443 PMCID: PMC6124338 DOI: 10.1016/j.mayocpiqo.2018.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective To assess variation in patient-reported experience in inpatient neurology patients. Patients and Methods We retrospectively identified 1045 patients 18 years and older admitted to a neurology service and discharged from January 1, 2013, through September 30, 2016, who completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Multivariable logistic regression evaluated the associations of patient factors with HCAHPS measures. Key driver analysis identified associations between HCAHPS measures and the Global score (combination of 0-10 hospital rating and likelihood to recommend). Multivariable logistic regression compared HCAHPS scores between neurology patients and those admitted to a neurosurgery (n=2190) or internal medicine (n=3401) service during the same period. Results Among patients admitted to a neurology service, overall (summary) scores did not vary significantly by diagnosis after adjustment for age, education, and overall health, but patients with neurologic diagnoses other than stroke, epilepsy, and neurodegenerative disease were more likely to report lower Pain Management scores compared with patients with cancer. Key driver analysis showed Care Transition scores as drivers of the Global score. After adjustment, general internal medicine service patients were more likely to report low Summary scores and neurosurgery service patients were significantly less likely to report low Summary scores compared with neurology service patients. Conclusion Efforts to improve how neurology patients experience their care should be aimed at targeting patients' perceptions of pain management, and improving care transitions is an important first-priority target for improvement. This analysis may help other institutions improve hospital rating, value-based payments, and patient-centered outcomes.
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Affiliation(s)
- Kristine T Hanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | | | | | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Cornelius A Thiels
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.,Department of Surgery, Mayo Clinic, Rochester, MN
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Patterson DF, Ho ML, Leavitt JA, Smischney NJ, Hocker SE, Wijdicks EF, Hodge DO, Chen JJW. Comparison of Ocular Ultrasonography and Magnetic Resonance Imaging for Detection of Increased Intracranial Pressure. Front Neurol 2018; 9:278. [PMID: 29740393 PMCID: PMC5928295 DOI: 10.3389/fneur.2018.00278] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/09/2018] [Indexed: 01/01/2023] Open
Abstract
Background/aims To evaluate and compare the performance of ocular ultrasonography (US) and magnetic resonance imaging (MRI) for detecting increased intracranial pressure (ICP) in patients with idiopathic intracranial hypertension (IIH). Methods Twenty-two patients with papilledema from IIH and 22 with pseudopapilledema were prospectively recruited based on funduscopic and clinical findings. Measurements of optic nerve sheath diameters (ONSDs) 3 mm behind the inner sclera were performed on B-scan US and axial T2-weighted MRI examinations. Pituitary-to-sella height ratio (pit/sella) was also calculated from sagittal T1-weighted MRI images. Lumbar puncture was performed in all patients with IIH and in five patients with pseudopapilledema. Results Average US and MRI ONSD were 4.4 (SD ± 0.7) and 5.2 ± 1.4 mm for the pseudopapilledema group and 5.2 ± 0.6 and 7.2 ± 1.6 mm for the papilledema group (p < 0.001). Average MRI pit/sella ratio was 0.7 ± 0.3 for the pseudopapilledema group and 0.3 ± 0.2 for the papilledema group (p < 0.001). Based on receiver-operator curve analysis, the optimal thresholds for detecting papilledema are US ONSD > 4.8 mm, MRI ONSD > 6.0 mm, and MRI pit/sella < 0.5. Combining a dilated US ONSD or MRI ONSD with a below-threshold MRI pit/sella ratio yielded a sensitivity of 73% and specificity of 96% for detecting IIH. Adding the US ONSD to the MRI ONSD and pit/sella ratio only increased the sensitivity by 5% and did not change specificity. Conclusion US and MRI provide measurements of ONSD that are well-correlated and sensitive markers for increased ICP. The combination of the ONSD and the pit/sella ratio can increase specificity for the diagnosis of IIH.
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Affiliation(s)
- David F Patterson
- Department of Ophthalmology, Mayo Clinic, Rochester, NY, United States
| | - Mai-Lan Ho
- Department of Radiology, Mayo Clinic, Rochester, NY, United States
| | | | | | - Sara E Hocker
- Department Neurology, Mayo Clinic, Rochester, NY, United States
| | | | - David O Hodge
- Department Health Sciences Research, Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, United States
| | - John Jing-Wei Chen
- Department of Ophthalmology, Mayo Clinic, Rochester, NY, United States.,Department Neurology, Mayo Clinic, Rochester, NY, United States
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Abstract
PURPOSE OF REVIEW Status epilepticus (SE) is a multisystem disorder. Initially, complications of a massive catecholamine release followed by the side effects of medical therapies, impact patients' outcomes. The aim of this article is to provide an updated summary of the systemic complications following SE. RECENT FINDINGS In recent years, the importance of the multifaceted nature of SE and its relationship with clinical outcomes has been increasingly recognized. The cumulative systemic effects of prolonged seizures and their treatment contribute to morbidity and mortality in this condition. Most systemic complications after SE are predictable. Anticipating their occurrence and respecting a number of simple guidelines may improve the prognosis of these patients.
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Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
| | - Sara E Hocker
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
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Snyder KA, Clarke MJ, Gilbertson JR, Hocker SE. Prompt Recognition and Management of Postoperative Intracranial Hypotension-Associated Venous Congestion: A Case Report. Neurocrit Care 2017; 24:448-53. [PMID: 26490779 DOI: 10.1007/s12028-015-0207-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Postoperative intracranial hypotension-associated venous congestion (PIHV) is an uncommon cause of clinical deterioration after a neurosurgical procedure that is often unrecognized until late in its course. Functional outcomes range from remarkable neurological recovery to death. Little is understood about the reason for deterioration in certain patients compared with improvement in others. A 68-year-old man with a progressive cervical myelopathy underwent an uncomplicated cervical decompression and alignment restoration at our hospital and suffered violent generalized tonic-clonic seizures intraoperatively and postoperatively. A postoperative head CT showed a right parietal hematoma, but no other cranial findings. A subsequent MRI demonstrated what we describe as early PIHV with symmetric T2 signal changes in the bilateral deep gray structures. No diffusion restriction corresponded to these areas. A CT myelogram revealed a considerable CSF collection within the operative bed. Upon returning to the operating room to localize the source of the leak, a large dural tear was identified off of midline with a bone chip alongside the defect. The defect was repaired, and the patient remained comatose for over a week postoperatively. He made a remarkable gradual recovery, and after a month in the hospital and rehabilitation, he returned home with relatively minimal neurological deficits. CONCLUSIONS We postulate that if caught early and treated aggressively, neurologic injury resulting from PIHV may be reversible despite initially ominous imaging. Neurosurgeons and neurointensivists should therefore be compelled to search for dural defects and return to the operating room for immediate repair.
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Affiliation(s)
- Kendall A Snyder
- Department of Neurosurgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Michelle J Clarke
- Department of Neurosurgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Julie R Gilbertson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sara E Hocker
- Department of Critical Care Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Wouda RM, Hocker SE, Higginbotham ML. Safety evaluation of combination carboplatin and toceranib phosphate (Palladia) in tumour-bearing dogs: A phase I dose finding study. Vet Comp Oncol 2017; 16:E52-E60. [PMID: 28799187 DOI: 10.1111/vco.12332] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/03/2017] [Accepted: 05/12/2017] [Indexed: 01/06/2023]
Abstract
Combining conventional cytotoxic maximum tolerated dose (MTD) chemotherapy with low-dose metronomic and/or anti-angiogenic agents is a exciting area of oncologic research. The objective of this study was to establish the MTD, safety and adverse event (AE) profile of 1 such drug combination. This prospective phase I dose-finding clinical trial assumed an open-label 3 + 3 cohort design. Client-owned dogs with 1 or more cytologically and/or histologically confirmed and macroscopically measurable, naive or recurrent, malignant tumours, were enrolled. No preference for tumour histology, grade or stage was expressed. Toceranib was administered at a dose of 2.75 mg kg-1 by mouth (PO) every other day (EOD), and carboplatin administered intravenously (IV) every 21 days at a starting dose of 200 mg m-2 . A total of 25% dose escalation was proposed for carboplatin, to a maximum of 300 mg m-2 . AEs were graded according to the Veterinary Cooperative Oncology Group's common terminology criteria for AEs (VCOG-CTCAE). Grade 3 haematologic or gastrointestinal AEs were nominated dose-limiting. Response to therapy was evaluated according to the VCOG's revised RECIST criteria. Eleven dogs were enrolled. Tumour histologies included sinonasal carcinoma, osteosarcoma, thyroid carcinoma, melanoma and apocrine gland anal sac adenocarcinoma. MTDs of carboplatin and toceranib were identified as 200 mg m-2 IV every 21 days and approximately 2.75 mg kg-1 PO EOD, respectively. The dose-limiting toxicity was neutropenia. Two dogs experienced a partial response, and 6 maintained stable disease. Combination carboplatin and toceranib chemotherapy was well-tolerated. Clinical benefit was observed in most cases. This protocol warrants further investigation in phase II/III trials.
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Affiliation(s)
- R M Wouda
- Department of Clinical Sciences, Kansas State University, College of Veterinary Medicine, Manhattan, Kansas
| | - S E Hocker
- Department of Clinical Sciences, Kansas State University, College of Veterinary Medicine, Manhattan, Kansas
| | - M L Higginbotham
- Department of Clinical Sciences, Kansas State University, College of Veterinary Medicine, Manhattan, Kansas
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Mittal MK, Rabinstein AA, Hocker SE, Pittock SJ, Wijdicks EFM, McKeon A. Autoimmune Encephalitis in the ICU: Analysis of Phenotypes, Serologic Findings, and Outcomes. Neurocrit Care 2017; 24:240-50. [PMID: 26319044 DOI: 10.1007/s12028-015-0196-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND To report the clinical and laboratory characteristics, clinical courses, and outcomes of Mayo Clinic, Rochester, MN, ICU-managed autoimmune encephalitis patients (January 1st 2003-December 31st 2012). METHODS Based on medical record review, twenty-five patients were assigned to Group 1 (had ≥1 of classic autoimmune encephalitis-specific IgGs, n = 13) or Group 2 (had ≥3 other characteristics supporting autoimmunity, n = 12). RESULTS Median admission age was 47 years (range 22-88); 17 were women. Initial symptoms included ≥1 of subacute confusion or cognitive decline, 13; seizures, 12; craniocervical pain, 5; and personality change, 4. Thirteen Group 1 patients were seropositive for ≥1 of VGKC-complex-IgG (6; including Lgi1-IgG in 2), NMDA-R-IgG (4), AMPA-R-IgG (1), ANNA-1 (1), Ma1/Ma2 antibody (1), and PCA-1 (1). Twelve Group 2 patients had ≥3 other findings supportive of an autoimmune diagnosis (median 4; range 3-5): ≥1 other antibody type detected, 9; an inflammatory CSF, 8; ≥1 coexisting autoimmune disease, 7; an immunotherapy response, 7; limbic encephalitic MRI changes, 5; a paraneoplastic cause, 4; and diagnostic neuropathological findings, 2. Among 11 patients ICU-managed for ≥4 days, neurological improvements were attributable to corticosteroids (5/7 treated), plasmapheresis (3/7), or rituximab (1/3). At last follow-up, 10 patients had died. Of the remaining 15 patients, 6 (24%) had mild or no disability, 3 (12%) had moderate cognitive problems, and 6 (24%) had dementia (1 was bed bound). Median modified Rankin score at last follow-up was 3 (range 0-6). CONCLUSIONS Good outcomes may occur in ICU-managed autoimmune encephalitis patients. Clinical and testing characteristics are diverse. Comprehensive diagnostics should be pursued to facilitate timely treatment.
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Affiliation(s)
- Manoj K Mittal
- Department of Neurology, College of Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.,Department of Neurology, University of Kansas Medical Center, Kansas, KS, USA
| | - Alejandro A Rabinstein
- Department of Neurology, College of Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Sara E Hocker
- Department of Neurology, College of Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Sean J Pittock
- Department of Neurology, College of Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eelco F M Wijdicks
- Department of Neurology, College of Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Andrew McKeon
- Department of Neurology, College of Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA. .,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA.
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Abstract
Background Previous studies evaluated the disposition of IV phenytoin loading doses and found that obese patients had increased drug distribution into excess body weight, larger volumes of distribution, and longer half-lives when compared to their nonobese counterparts. We assess the safety and efficacy of fosphenytoin loading doses in patients with different body mass indices (BMIs). Methods A retrospective chart review was conducted in 410 patients who received fosphenytoin. Patients were divided into 2 groups: BMI <30 (nonobese) and BMI ≥30 (obese). Patient demographics, fosphenytoin dose administered in mg/kg body weight, renal and liver function tests, fosphenytoin drug levels, and pre- and post-fosphenytoin administration vital signs were collected to assess for adverse events. Necessity of additional antiepileptic loading doses was used as a surrogate for clinical efficacy. Results The median dose of fosphenytoin administered was 19 mg/kg (interquartile range 15-20). The most frequently encountered adverse event was hypotension, which occurred in 39% of the cohort. Using a Bonferroni adjustment for multiple comparisons, there were no differences in adverse events between the 2 groups. The need for additional antiepileptic loading doses was not different between the 2 groups (p = 0.07). Conclusions The incidence of adverse events and the need for repeat loading antiepileptic medications was similar between the 2 groups. From our findings, the patients in our study did not receive empiric loading dose adjustments and the current method of loading fosphenytoin achieves similar outcomes, regardless of the patient's BMI.
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Scharf EL, Fugate JE, Hocker SE. Extensive Mobile Thrombus of the Internal Carotid Discovered After Intravenous Thrombolysis: What Do I Do Now? Neurohospitalist 2016; 7:96-99. [PMID: 28400904 DOI: 10.1177/1941874416663280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
This case report describes a rare presentation of ischemic stroke secondary to an extensive internal carotid artery thrombus, subsequent therapeutic dilemma, and clinical management. A 58-year-old man was administered intravenous (IV) thrombolysis for right middle cerebral artery territory ischemic stroke symptoms. A computed tomography angiogram of the head and neck following thrombolysis showed a longitudinally extensive internal carotid artery thrombus originating at the region of high-grade calcific stenosis. Mechanical embolectomy was deferred because of risk of clot dislodgement and mild neurological symptoms. Recumbency and hemodynamic augmentation were used acutely to support cerebral perfusion. Anticoagulation was started 24 hours after thrombolysis. Carotid endarterectomy was completed successfully within 1 week of presentation. Clinical outcome was satisfactory with discharge modified Rankin Scale score 0. A longitudinally extensive carotid artery thrombus poses a risk of dislodgement and hemispheric stroke. Optimal management in these cases is not known with certainty. In our case, IV thrombolysis, hemodynamic augmentation, delayed anticoagulation, and carotid endarterectomy resulted in a favorable clinical outcome.
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Abstract
This chapter reviews the neurologic complications of medications administered in the hospital setting, by class, introducing both common and less common side effects. Detail is devoted to the interaction between pain, analgesia, sedation, and their residual consequences. Antimicrobials are given in nearly every hospital setting, and we review their capacity to produce neurologic sequelae with special devotion to cefepime and the antiviral treatment of human immunodeficiency virus. The management of hemorrhagic stroke has become more complex with the introduction of novel oral anticoagulants, and we provide an update on what is known about reversal of the new oral anticoagulants. Both central and peripheral nervous system complications of immunosuppressants and chemotherapies are reviewed. Because diagnosis is generally based on clinical acumen, alone, neurotoxic syndromes resulting from psychotropic medications may be easily overlooked until severe dysautonomia develops. We include a practical approach to the diagnosis of serotonin syndrome and neuroleptic malignant syndrome.
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Affiliation(s)
- Elliot T Dawson
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA.
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Abstract
PURPOSE OF REVIEW Status epilepticus, which is simultaneously a neurologic and systemic emergency, often results in significant disability and may be fatal. This article presents a pragmatic approach to the evaluation and management of status epilepticus in adults for the practicing clinician. RECENT FINDINGS Rapid recognition, treatment respecting a written protocol, and careful attention to potential complications may limit sequelae. Studies aimed at earlier identification of etiologies in cryptogenic status epilepticus and improving the treatment of established status epilepticus are urgently needed to limit the development of refractoriness. SUMMARY This article reviews the guidelines and up-to-date information on the use of both pharmacologic and nonpharmacologic therapies in status epilepticus and discusses the shifts in our understanding of the balance between the need for aggressive control of seizures and the risks of treatment. This article also presents a suggested approach to the evaluation and management of common types of status epilepticus and explores future directions.
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. Urgent Options in Brain Metastasis. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. Acute Paraplegia After Aortic Surgery. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. When Blood Pressure Needs Control After Stroke. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. The First Week After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. When to Retrieve a Clot in Acute Stroke. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. Acute Fever and Shock After Ruptured Cerebral Aneurysm. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. When to Place an Intracranial Pressure Monitor. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. When to Mention Organ Donation. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. Not Yet Brain Dead. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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41
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. When a Single EEG Is Not Enough. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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42
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. Swollen Ischemic Brain and When to Call the Neurosurgeon. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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43
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. Wild and Agitated After Acute Abdominal Surgery. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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44
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. More on Delayed Cerebral Ischemia and Neurointervention After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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45
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. Sweaty, Febrile, and Tachypneic After Traumatic Brain Injury. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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46
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. Hemorrhage into a Pituitary Tumor. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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47
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. When Status Epilepticus Does Not Respond to First Treatment. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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48
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. What Neurologists Know About Outcome in Post-Resuscitation Coma and What Other Physicians Want to Know. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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49
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. Struggling to Get a Patient with Myasthenia Gravis off the Ventilator. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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50
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Wijdicks EFM, Rabinstein AA, Hocker SE, Fugate JE. Awake and Then Not Awake After Brain Surgery. Neurocrit Care 2016. [DOI: 10.1093/med/9780190602659.003.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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