Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage

Background and purposePrimary pontine hemorrhage (PPH) accounts aproximately for about 5–10% of intracranial hemorrhages, and PPHs are known to have a much less uniform prognosis. We aimed to evaluate the clinical and radiological predictors affecting the mortality in 32 patients with PPH.Material and methodsWe retrospectively evaluated the data of 32 patients with PPH admitted to our clinic between 1994 and 2004. We divided the patients into two groups: (1) patients who survived (14 patients), and (2) patients who died (18 patients). The two groups were compared for age, gender, diabetes mellitus, hypertension, initial clinical status, initial GCS, pupillary abnormalities, ophthalmoparesis, volume and localisation of hemorrhage, intraventricular and extrapontine extension, necessity of mechanical ventilation and hydrocephalus. The hematoma volumes were measured with the formulation described by Broderick.ResultsEighteen patients (56%) died and 14 patients (44%) survived. The patients who died (61.3 ± 8.8) were older than the survivors (56.4 ± 11.0), but the difference was not statistically significant. The mean GCS was 4.4 ± 0.2, the mean hematoma volume was 9.9 ± 3.3 ml for patients who died and the mean GCS was 10.1 ± 3.3, the mean hematoma volume was 3.3 ± 1.2 ml for survivors (p < 0.001). Coma on admission (p = 0.001), extrapontine extension (p = 0.001), intraventricular extension (p = 0.019), necessity of mechanical ventilation (p = 0.007), hydrocephalus (p = 0.024), massive and bilateral tegmental localisation (p = 0.006) were found statistically significant predictors for mortality with univariate comparison, and coma on admission (p = 0.038) was the only significant predictor with multivariate regression analysis.ConclusionIn patients with PPH, it is important to know the prognostic factors for mortality for planning the treatment protocol, and coma and bad clinical status on admission was found the only significant prognostic predictor for mortality with multivariate regression analysis.     

Should we treat patients with impaired consciousness and periodic patterns on EEG?

PurposeThe significance of periodic EEG patterns in patients with impaired consciousness is controversial. We aimed to determine if treating these patterns influences clinical outcome.MethodWe studied all patients who had periodic discharges on their EEG recordings from January 2007 to December 2009. Patients with clinical seizures within the preceding 24 h, or with unequivocal electrographical seizure activity were excluded. Logistic regression was performed to analyze for factors associated with (a) mortality (b) functional status (c) resolution of EEG pattern.ResultsOf the 4246 patients who had EEG, 111 (2.6%) had periodic EEG patterns. 64 met inclusion criteria. In adjusted analysis, higher mortality was associated with acute symptomatic etiology (OR 17.74, 95% CI 1.61–196.07, p = 0.019), and presence of clinical seizures (OR 4.73, 95% CI 1.10–20.34, p = 0.037). For each unit decrement of GCS, the odds of inpatient mortality and a poorer functional state on discharge increased by 23% (95% CI 7–37%, p = 0.009) and 33% (95% CI 9–51%, p = 0.011) respectively. Administration of abortive therapy was an independent risk factor for poorer functional status on discharge (adjusted OR 41.39, 95% CI 2.88–594.42, p = 0.006), while patients with history of pre-existing cerebral disease appeared more likely to return to baseline functional status on discharge (unadjusted OR 5.00, 95% CI 1.40–17.86, p = 0.013).ConclusionTreatment of periodic EEG patterns does not independently improve clinical outcome of patients with impaired conscious levels. Occurrence of seizures remote to the time of EEG and lower GCS scores independently predict poor prognoses.     

Prediction,clinical characteristics and prognosis of intracerebral hemorrhage in hepatocellular carcinoma patients with intracerebral metastasis

The clinical characteristics of intracerebral hemorrhage (ICH) in hepatocellular carcinoma (HCC) patients with intracerebral metastasis (IcM) have not been reported on extensively. We compared the clinical characteristics between patients with ICH (w-ICH, 18 patients) and without ICH (wo-ICH, 24 patients) in HCC patients with IcM. Using multivariate logistic regression, only habitual alcohol consumption is a significant predictor of ICH in HCC patients with IcM (adjusted odds ratio [OR] = 4.7, 95% CI = 1.26–17.71, p = 0.022). Patients with ICH also had lower Glasgow Coma Scale scores at the time of admission (p = 0.032) and lower incidence of infratentorial metastasis (p = 0.014). Using correlation analysis, only blood platelet count on admission was positively correlated with survival duration after the diagnosis of IcM in the wo-ICH group (p = 0.000) but not in the w-ICH group.     

Impact of recanalisation by mechanical thrombectomy in mild acute ischemic stroke with large anterior vessel occlusion

BackgroundThe net clinical benefit of mechanical thrombectomy (MT) in patients presenting acute anterior circulation ischemic stroke with large-vessel occlusion (AIS–LVO) and mild neurological deficit is uncertain.AimsTo investigate efficacy and safety of MT in patients with acute AIS–LVO and mild neurological deficit by evaluating i) the influence of recanalisation on three-month outcome and ii) mortality, symptomatic intracerebral hemorrhage (sICH) and procedural complications.MethodsWe included consecutive patients with acute AIS–LVO and National Institute of Stroke Scale (NIHSS) score < 8, treated by MT at Lille University Hospital. Recanalisation was graded according to modified thrombolysis in cerebral infarction (mTICI) score, mTICI 2b/2c/3 being considered successful. We recorded procedural complications and classified intra-cerebral hemorrhages (ICH) and sICH according with European Cooperative Acute Stroke Study (ECASS) and ECASS2 criteria. Three-month outcome was evaluated by modified Rankin scale (mRS). Excellent and favourable outcomes were respectively defined as mRS 0–1 and 0–2 (or similar to pre-stroke).ResultsWe included 95 patients. At three months, 56 patients (59. 0%) achieved an excellent outcome and 69 (72, 6%) a favourable outcome, both being more frequent in patients with successful recanalisation than in patients without (excellent outcome 71, 1% versus 10, 5%, P < 0.001 and favourable outcome 82.9% versus 31.6%, P < 0.001). The difference remained unchanged after adjustment for age and pre-MT infarct volume. Similar results were observed in patients with pre-MT NIHSS ≤ 5. Death occurred in five patients (5.3%), procedural complications in 12 (12.6%), any ICH in 38 (40.0%), including 3 (3.2%) sICH.ConclusionsAchieving successful recanalisation appears beneficial and safe in acute AIS–LVO patients with NIHSS < 8 before MT.     

Long-term outcome and predictors of resective surgery prognosis in patients with refractory extratemporal epilepsy

PurposeWe analyzed the long-term postoperative outcome and possible predictive factors of the outcome in surgically treated patients with refractory extratemporal epilepsy.MethodsWe retrospectively analyzed 73 patients who had undergone resective surgery at the Epilepsy Center Brno between 1995 and 2010 and who had reached at least 1 year outcome after the surgery. The average age at surgery was 28.3 ± 11.4 years. Magnetic resonance imaging (MRI) did not reveal any lesion in 24 patients (32.9%). Surgical outcome was assessed annually using Engel's modified classification until 5 years after surgery and at the latest follow-up visit.ResultsFollowing the surgery, Engel Class I outcome was found in 52.1% of patients after 1 year, in 55.0% after 5 years, and in 50.7% at the last follow-up visit (average 6.15 ± 3.84 years). Of the patients who reached the 5-year follow-up visit (average of the last follow-up 9.23 years), 37.5% were classified as Engel IA at each follow-up visit. Tumorous etiology and lesions seen in preoperative MRI were associated with significantly better outcome (p = 0.035; p < 0.01). Postoperatively, 9.6% patients had permanent neurological deficits.ConclusionSurgical treatment of refractory extratemporal epilepsy is an effective procedure. The presence of a visible MRI-detected lesion and tumorous etiology is associated with significantly better outcome than the absence of MRI-detected lesion or other etiology.     

Predicting long-term outcome in poor grade aneurysmal subarachnoid haemorrhage patients utilising the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is the most universally accepted system for grading level of consciousness. Predicting outcome is particularly difficult in poor grade aneurysmal subarachnoid haemorrhage (aSAH) patients. We hypothesised that the GCS and individual examination components would correlate with long-term outcome and have varying prognostic value depending on assessment time points. GCS scores of 160 aSAH patients presenting in stupor or coma were prospectively recorded on admission and each subsequent day until hospital day 14. Early treatment was planned for each patient unless the patient’s family refused aggressive intervention or the patient died before surgery. Outcomes were assessed by the modified Rankin scale (mRS) at 14 days, 3 months, and one year.All patients who did not receive surgical treatment died within one year. Of the 104 patients who received surgical treatment, 13.5% of them had a favourable outcome at 14 days, 38.5% at 3 months, and 51% at one year (p < 0.0001). Admission GCS scores significantly correlated with outcome (Spearman rank test, rs = 0.472, p < 0.0001). On admission, motor examination correlated best with one-year outcome (rs = 0.533, p < 0.0001). Each point increase in motor examination predicted a 1.8-fold increased odds of favourable long-term outcome (95% confidence interval [CI], 1.4–2.3). At discharge, eye examination (rs = 0.760, p < 0.0001) correlated best with one-year outcome, and a one point increase in eye examination predicted a 3.1-fold increased odds of favourable outcome (95% CI, 1.8–5.4). During hospitalisation, the best eye exam (rs = 0.738, p < 0.0001) and worst motor exam (rs = 0.612, p < 0.0001) were the most highly correlated with the one-year outcome.Long-term follow-up is necessary when evaluating recovery after aSAH, as outcomes improve significantly during the first year. The GCS and its individual components correlate well with long-term outcome. Admission motor examination and spontaneous eye opening during hospitalisation are most predictive of favourable recovery.     

Effects of plasma D-dimer levels on early mortality and long-term functional outcome after spontaneous intracerebral hemorrhage

The activation of hemostatic systems has been detected in spontaneous intracerebral hemorrhage (ICH) patients. The influence of plasma D-dimer levels on clinical outcome remains unclear. This study aimed to investigate the impact of elevated plasma D-dimer levels on early mortality and long-term functional outcome in spontaneous ICH. A total of 259 spontaneous ICH patients (<24 hours from ictus) between November 2010 and October 2011 were included. Clinical information and radiological findings were collected at admission. Spearman correlation analyses revealed that D-dimer concentrations were correlated with midline shift, hematoma volume, intraventricular hemorrhage (IVH) score and Glasgow Coma Scale score. Patients with subarachnoid extension had significantly higher D-dimer levels than those without SAH extension. Comparison of patients with IVH and those without yielded a similar result. Multivariate stepwise backward logistic analysis identified plasma D-dimer levels as an independent risk factor for 7 day mortality (adjusted odds ratio [OR] = 1.237, 95% confidence interval [CI] 1.017–1.504, p = 0.033) and 3 month poor functional outcome (modified Rankin Scale score ⩾3) (adjusted OR = 2.279, 95% CI 1.130–6.595, p = 0.026). The mechanisms by which elevated D-dimer affects the prognoses of spontaneous ICH patients remain unclear and require clarification in future studies.     

Clinical features and outcome of super-refractory status epilepticus: A retrospective analysis in West China

PurposeData about super-refractory status epilepticus (SRSE) are scarce. This study aimed to assess the clinical features and outcome of patients with SRSE.MethodClinical features of all SRSE patients admitted to the Neurologic Intensive Care Unit (NICU)/Neurology Department of West China Hospital, Sichuan University, between January 2010 and August 2013, were retrospectively analyzed. Outcome at discharge, at the three-month and long-term follow-ups were evaluated using the Glasgow Outcome Scale (GOS). Possible predictors of mortality and outcome were also evaluated.ResultsThirteen patients with SRSE were included. Young patients with encephalitis accounted for the majority of the series (61.5%). In-hospital mortality was 15.4% (2/13), and the three-month mortality was 36.4% (4/11; two patients ceasing therapy were excluded). At the long-term follow-up, 18.2% of patients improved and 45.5% of patients recovered. Patients of older age and those with multiple complications had higher mortality compared with those of younger age and those with fewer complications. For survivors, functional outcome had significantly improved at three-month follow-up (GOS score = 4.1 ± 1.2) compared to that at discharge (GOS score = 3.1 ± 1.2, P < 0.05). Long duration of anesthesia, etiology of encephalitis and positive neuroimaging findings tended to be associated with poor functional outcome.ConclusionWe conclude that the typical patient susceptible to development of SRSE in West China is a young patient with encephalitis. Older age and multiple complications increase the risk of death. Most patients can survive with aggressive therapy, and their functional outcome improves over time.     

Risk factors and clinical characteristics of non-promyelocytic acute myeloid leukemia of intracerebral hemorrhage: A single center study in China

BackgroundAlthough high mortality in patients with acute leukemia (AL) is associated with intracranial hemorrhage (ICH), the clinical features and pathogenesis of AL patients with cerebral hemorrhage are not well known.MethodsWe diagnosed 90 patients with ICH from a total of 1467 patients with non-promyelocytic AL who had been hospitalized in the First Affiliated Hospital of Medical School of Zhejiang University from January 2010 to October 2015. Moreover, the risk factors of ICH death were evaluated.ResultMedian age at ICH was 51 years old, in which men accounted for 52.2%. They also accounted for 85.6% of acute myeloid leukemia. The relative incidence of ICH was the highest in M2 and M5 (60.1%). ICH presented with higher peripheral blood white blood cell count (WBC) (P < 0.001), lower peripheral platelet counts (P < 0.001), lower albumin (P < 0.001), lower fibrous protein (P < 0.001) and prolongation of prothrombin time (P < 0.001) compared to those observed in the patients of NICH group; multivariate analysis, independent risk factors for death in patients with ICH include: WBC ≥ 30.00 × 109/l and prothrombin time ≥ 12.91 s.ConclusionsLeukocytosis and coagulation dysfunctions might be the main pathogenesis of acute leukemia complicated with cerebral hemorrhage.     

Seizures and antiepileptic drugs in patients with spontaneous intracerebral hemorrhages

PurposePatients with intracerebral hemorrhage (ICH) are often initiated on antiepileptic drugs without a clear indication. We compared the percentage of patients with spontaneous ICH who had seizures at onset or during hospitalization, and examined empiric use of antiepileptic drugs (AEDs) in these patients in 2 cohorts 10 years apart.MethodsUsing a clinical data registry at a tertiary care adult hospital, we retrospectively selected admissions for spontaneous ICH between 1/1/99–12/31/00 (Cohort A, n = 30) and 1/1/09–12/31/10 (Cohort B, n = 108). Clinical, neurophysiological and radiological data were collected in both cohorts.ResultsIn Cohorts A and B respectively, AEDs were started in 53.3% and 50.0%, and continued on discharge in 50.0% and 20.4% of patients; 86.6% and 59.1% of patients discharged on AEDs did not have a clinical/electrographic seizure or epileptiform EEG findings. Seizures occurred in 6.6% and 13.0% in Cohorts A and B respectively. The presence of a seizure at presentation (p = 0.01) and during hospitalization (p = 0.02) were predictors for continuing AED on discharge.ConclusionIn both cohorts, a significant number of patients were discharged on AEDs without a clear indication, though there is a change in practice between the two cohorts.     

Traumatic interhemispheric subdural haematoma: Study of 35 cases

The clinical and radiological findings, management, and outcomes in 35 patients with traumatic interhemispheric subdural haematoma (ISH) were reviewed retrospectively. Twenty-five patients had favourable outcomes and 10 had poor outcomes. All patients were treated conservatively for ISH. Univariate analysis found that the Glasgow Coma Scale (GCS) score (p < 0.001), hypovolemic shock (p = 0.018), skull fracture (p = 0.008), convexity or posterior fossa subdural haematoma (p = 0.008), and subarachnoid haemorrhage (SAH) were correlated with outcome (p < 0.001). Multivariate analysis showed that GCS score (p = 0.031; odds ratio [OR], 0.6; 95% confidence interval [CI], 0.3–0.9) and the presence of SAH (p = 0.023; OR, 14.2; 95% CI, 1.5–138.2) were significantly related to poor outcome. This study provides important information on the clinicoradiological findings and prognoses in patients with traumatic ISH.     

Evaluation of a revised Glasgow Coma Score scale in predicting long-term outcome of poor grade aneurysmal subarachnoid hemorrhage patients

Although many scales attempt to predict outcome following aneurysmal subarachnoid hemorrhage (aSAH), none have achieved universal acceptance, and most scales in common use are not statistically derived. We propose a statistically validated scale for poor grade aSAH patients that combines the Hunt and Hess grades and the Glasgow Coma Scale (GCS) scores; we refer to this as the Poor Grade GCS (PGS).The GCS scores of 160 poor grade aSAH patients (Hunt and Hess Grades 4 and 5) were recorded throughout their hospital stay. Outcomes were assessed by the modified Rankin scale (mRS). Analysis of variance and the Chi-square test were used to guide an analysis of GCS breakpoints according to outcomes. Multivariable logistic regression analysis was used to assess the ability of the Hunt and Hess, GCS, World Federation of Neurological Surgeons Grading Scale, and the PGS to predict long-term outcome.Outcome analysis revealed significant breakpoints in admission GCS scores: PGS-A (GCS 10–12); PGS-B (GCS 8–9); PGS-C (GCS 5–7); PGS-D (GCS 3–4) (p < 0.001). In surgical patients, 95.2% of PGS-A, 58.1% of PGS-B, 35.4% of PGS-C, and 28.6% of PGS-D had a favorable one-year outcome. When controlling for age, sex, and operation status, PGS was the only scale predictive of long-term outcome. The odds ratios (OR) for unfavorable outcome according to PGS admission scores (with PGS-A as the reference) were: PGS-B, OR = 14.2 (95% CI 1.5–140.5); PGS-C, OR = 38.5 (95% CI 4.2–340.0); and PGS-D, OR = 63.4 (95% CI 5.6–707.1). In addition to PGS admission scores, an age of 70 or greater was a significant predictor of poor outcome with an OR of 7.5 (95% CI 1.8–30.7). No patients with a PGS-C or PGS-D over the age of 70 had a favorable long-term outcome.Therefore, elements of the Hunt and Hess and GCS can be combined into the PGS to predict long-term outcome in poor grade aSAH patients. However, patients with PGS-C and PGS-D over the age of 70 should be assessed carefully prior to definitive treatment.     

Sleep-disordered breathing: Impact on functional outcome of ischemic stroke patients

Background and purposeSleep-disordered breathing (SDB) is more prevalent in stroke patients than age- and sex-matched controls, but the relationship between SDB and functional outcome of stroke patients is unclear. The aim of our study was to determine the prevalence of SDB in ischemic stroke and its influence on functional outcome at 3 and 6 months after stroke onset.MethodsIn a prospective study, 60 patients were selected by polysomnography (PSG). The apnea–hypopnea index (AHI) was determined 6.5 ± 3.2 days after stroke onset. Neurologic severity at admission was assessed by the Scandinavian Stroke Scale (SSS) and outcome by the Barthel Index (BI). Patients were evaluated on admission, 3 and 6 months after stroke onset.ResultsAmong the 60 patients, 39 (65%) patients had SDB (AHI ? 5); of these, 30 patients (50%) had AHI ? 15 and 18 (30%) > 30. On Logistic regression analysis, the BI at 3 months was independently predicted by SSS (OR = 0.74, 95% CI [0.62–0.88], P = 0.001) and AHI (OR = 1.09, 95% CI [1.02–1.17], P < 0.05). At 6 months, the BI was predicted only by SSS (OR = 0.83, 95% CI [0.74–0.92], P = 0.001).ConclusionsSDB is common in patients during acute phase after stroke onset. SDB appears to be associated with a worse functional outcome during the early recovery period following stroke, increasing the likelihood of dependency.     

Prognostic value of periodic electroencephalographic discharges for neurological patients with profound disturbances of consciousness

ObjectiveTo examine if periodic EEG discharges (PDs) predict poor outcome and development of epilepsy in patients with acute brain illnesses irrespective of underlying cerebral pathology.MethodsIn case-control study we retrospectively analyzed outcome of 102 patients with PDs and 102 age-, gender- and etiology matched controls without PDs.ResultsOf cases, 46.1% had lateralized PDs (LPDs), 3.9% bilateral PDs (BIPDs), 15.7% generalized PDs (GPDs) and 34.3% had combinations thereof. Etiology: Stroke was most common cause of LPDs (53%), cardiac arrest of GPDs (10.5%), previous stroke, CNS infection, anoxia and metabolic encephalopathy all caused 1 case of BIPDs. Outcome: Mortality rate and acquired disability was significantly higher in patients with PDs than in controls, odds ratio (OR) 2.5, 95% CI 1.43–4.40 (p = 0.001). Patients with PDs without superimposed EEG activity had worse outcome than patients with superimposed EEG activity. Tardive epilepsy: Patients with LPDs associated with fast superimposed EEG activity (LPDs-plus) had higher risk for tardive epilepsy than patients with LPDs alone (p = 0.034).ConclusionPDs predicted poor functional outcome and patients with LPDs-plus had higher risk for later development of epilepsy.SignificanceDetailed evaluation of PDs provided valuable prognostic information in neurological patients with disturbed consciousness.     

Plasma brain natriuretic peptide is elevated in the acute phase of intracerebral hemorrhage

Previous reports have shown that plasma brain natriuretic peptide (BNP) levels are increased in patients with subarachnoid hemorrhage and ischemic stroke. We examined BNP in patients with intracerebral hemorrhage (ICH). Between June 2006 and February 2010, we prospectively enrolled consecutive patients with acute ICH within 24 hours of onset. The plasma BNP level was measured twice, on admission and 4 weeks after onset or at discharge. We investigated whether plasma BNP was elevated in the acute phase of ICH and associated factors. The mean ± standard deviation (SD) plasma BNP level of all patients was 71.1 ± 104.1 pg/mL. The log BNP level positively correlated with the cardio–thoracic ratio (r = 0.240, p = 0.0001). Moreover, BNP was significantly associated with intraventricular extension (p = 0.0039) and hydrocephalus (p = 0.0046). The mean ± SD BNP level of patients with cerebellar hemorrhage was the highest (130.2 ± 152.0 pg/mL), followed by brainstem (84.5 ± 170.6 pg/mL), lobar (72.4 ± 148.1 pg/mL), thalamus (64.8 ± 72.1 pg/mL), and putamen (59.9 ± 62.6 pg/mL) hemorrhages. In 185 patients, BNP was measured in the subacute phase of ICH. The BNP level in the acute phase of ICH was significantly higher than that in the subacute phase of ICH (69.3 ± 108.1 versus 21.7 ± 23.5 pg/mL, p < 0.0001). In conclusion, plasma BNP appears to be elevated in the acute phase of ICH, particularly in those with cerebellar lesions.     

Direct access to a hospital offering intravenous thrombolysis therapy improves functional outcome of acute ischemic stroke patients

Referral from other hospitals is one of the primary causes of delayed thrombolysis therapy after acute ischemic stroke (AIS). We aimed to evaluate whether direct access to a hospital offering intravenous thrombolysis therapy was associated with good functional outcome in AIS patients treated with thrombolysis. We enrolled patients who received intravenous thrombolysis within 3 hours of symptom onset at our stroke center. We divided these patients into two groups: those with a direct admission to our stroke center and those with indirect admission by referral from other community hospitals. We investigated onset-to-door time and onset-to-recombinant tissue plasminogen activator (rtPA) time according to admission mode. We then assessed the association between a direct admission and favorable outcome at 90 days. A total of 232 patients (mean age of 66.6 years, median National Institutes of Health Stroke Scale score of 10) were included. A total of 48.7% of AIS patients treated with intravenous thrombolytic therapy were transferred from other hospitals. Patients who were directly admitted to our stroke center had a shorter onset-to-door time (61 versus 120 minutes, p < 0.001) and onset-to-rtPA time (103 versus 155 minutes, p < 0.001) than those referred from other hospitals. Direct admission was associated with a good outcome with an odds ratio of 2.03 (95% confidence interval 1.051–3.917, p = 0.035), after adjusting for baseline variables. Thrombolysis after direct admission to a hospital offering intravenous thrombolysis therapy could shorten onset-to-rtPA time and improve stroke outcome in patients with AIS.     

Status epilepticus in pregnancy: Etiology,management, and clinical outcomes

BackgroundStatus epilepticus (SE) in pregnancy carries significant risk to both mother and fetus. There is limited literature available on SE occurring in pregnancy world-over, with majority being from obstetric centers.MethodsAll women who developed SE related to pregnancy (gestation, labor, or puerperium) between January 2000 and December 2016 were included in the study. Data were collected from our SE registry, maintained, and archived in the institute. The variables influencing the maternal and fetal outcome were compared using Student's t-test for continuous variables and Fisher's exact test for discrete variables.ResultsDuring the 16-year study period, a total of 348 SE events were recorded in 294 patients. Among these, there were 138 women, of which 17 had SE related to pregnancy. The etiology of SE was remote symptomatic in two and acute symptomatic in 15 patients. The various causes detected after initial evaluation for acute symptomatic SE were eclampsia (n = 4), posterior reversible encephalopathy syndrome due to various causes other than eclampsia (n = 6), cortical venous thrombosis (n = 3), subarachnoid hemorrhage (n = 1), and NMDA receptor antibody-mediated encephalitis (n = 1).13 of 17 women with SE (76%) had good outcome. Majority of the fetuses had good outcomes, i.e., Category 1 (n = 9, 57%). Duration of intensive care unit stay (p = 0.029) and Status Epilepticus Severity Score (p = 0.0324) at admission, were found to be significantly associated with poor outcomes.ConclusionIn any patient presenting with SE occurring in pregnancy, though eclampsia is presumed to be the most common overall cause; it is relevant to consider other etiologies such as posterior reversible encephalopathy syndrome, cortical venous thrombosis, and autoimmune encephalitis especially in cases presenting with refractory SE. Posterior reversible encephalopathy may occur in pregnancy due to diverse etiologies other than eclampsia.     

Dynamic evolution of D-dimer level in cerebrospinal fluid predicts poor outcome in patients with spontaneous intracerebral hemorrhage combined with intraventricular hemorrhage

The risk of mortality in patients with intracerebral hemorrhage (ICH) significantly increases when complicated by intraventricular hemorrhage (IVH). We hypothesize that serial measurement of cerebrospinal fluid (CSF) D-dimer levels in patients with both ICH and IVH may serve as an early marker of IVH severity. We performed a prospective study of 43 consecutive ICH patients combined with IVH and external ventricular drainage placement admitted in our institution from 2005–2006. IVH severity (Graeb score) and fibrinolytic activity were evaluated continuously for 7 days using CT scans and CSF D-dimer levels. The primary outcome was 30 day mortality. Overall 30 day mortality was 26% (n = 11), with eight deaths (72.7%) after 3 days (D3). Graeb score and CSF D-dimer on admission (D0) were not significantly different between survivors and non-survivors. The temporal profiles of both parameters were distinctly different, with a downward trend in survivors and an upward trend in non-survivors. A mortality rate of 54% was observed between D0–D3 when both scores increased during this interval. In contrast, the mortality was only 4% when both measures decreased during this interval. Early phase (D0–D3) CSF D-dimer or Graeb score change demonstrated high sensitivity of 88% and specificity of 81% when predicting 30 day mortality. Early phase CSF D-dimer change in patients with both ICH and IVH is accurate in predicting mortality and may be utilized as a cost-effective surrogate indicator of IVH severity. Serial monitoring of CSF D-dimer dynamic changes is useful for early identification of patients with hematoma progression and poor outcome.     

The role of the standard 20 minute EEG recording in the comatose patient

Non-convulsive seizures and non-convulsive status epilepticus (NCSE) are believed common in comatose patients and are suggested to worsen outcome. The purpose of this study was to prospectively evaluate outcome in patients in critical care units in whom NCSE was suspected to determine how often evidence of seizure activity existed based on an isolated standard 20 minute electroencephalogram (EEG) and to determine what clinical factors predicted outcome. We prospectively reviewed EEGs and clinical charts of patients admitted to a critical care unit at a tertiary care center who were suspected to have non-convulsive seizures. Outcomes were correlated with EEG findings, clinical factors, and acute therapies using univariate and multivariate logistic analyses. Of 189 patients, complete information was available in 169. Eighty-one (47.9%) patients died, 67 (39.6%) were discharged home, and 21 (12.4%) were discharged to long-term care. Four patients had electroencephalographic seizures, two of whom had no clinical manifestations (i.e. non-convulsive). On univariate analysis, increased age, an admitting diagnosis of cardiac arrest, a Glasgow Coma Scale (GCS) score ? 8, and burst suppression were correlated significantly with poor outcome. A past history of seizures and unequivocal tonic–clonic convulsions were correlated significantly with a better outcome. On multivariate analysis, increased age, cardiac arrest, and a GCS score ? 8 were associated with increased mortality (p < 0.05). Clinical factors, including age, underlying etiology and GCS score are the most important predicators of outcome in coma. A standard 20 minute EEG did not correlate with a high detection rate of seizure activity. Furthermore, EEG patterns and treatment with anticonvulsant medications did not correlate with outcome.     

Post-traumatic seizures—A prospective study from a tertiary level trauma center in a developing country

RationaleNo large studies till date are available from India on post-traumatic seizures (PTS).MethodsThis is a prospective observational study of 520 patients with traumatic brain injury (TBI) (July 2007–2008). Patients admitted after 24 h of injury, with Glasgow coma scale (GCS) ≤ 4 were excluded.ResultsAt a median follow-up of 386 days, 59 (11.4%) patients developed PTS. Incidence of immediate, early and late onset seizure were 6.5%, 2.1% and 2.7% respectively. In children, incidence of PTS was 18.3%. On univariate analysis, females, of age <10 years, with associated medical problems and with delayed loss of consciousness and poor GCS (<9), following fall from height, had significantly higher odds of PTS. On multivariate analysis, the risk of PTS was 3.7 times higher in patients who had fallen from height, 4.4 times higher in associated medical problems, and 3.7 times higher in severe head injury (GCS < 9) at presentation. PTS was associated with poor Glasgow outcome score and higher incidence of behavioral abnormality on follow up. 32% patient with PTS developed recurrent delayed seizures. Seizure recurrence was significantly higher in late onset PTS. PTS affected overall outcome of the patients in severe head injury.ConclusionThe risk of PTS was higher in patients who sustained fall from height, in GCS < 9, and associated medical problems. About 1/3rd of the patients with early PTS developed recurrent delayed seizures.