Electroencephalography of mechanically ventilated patients at high risk of delirium.

Neurophysiological exploration of ICU delirium is limited. Here, we examined EEG characteristics of medical-surgical critically ill patients with new-onset altered consciousness state at high risk for ICU delirium. Pre-planned analysis of non-neurological mechanically ventilated medical-surgical ICU subjects, who underwent a prospective multicenter randomized, controlled EEG study (NCT03129438, April 2017-November 2018). EEG characteristics, according to the 2012 ACNS nomenclature, included background activity, rhythmic periodic patterns/epileptic activity, amplitude, frequency, stimulus-induced discharges, triphasic waves, reactivity, and NREM sleep. We explored EEG findings in delirious versus non-delirious patients, specifically focusing on the presence of burst-suppression and rhythmic periodic patterns (ictal-interictal continuum), and ictal activity. We analyzed 91 patients (median age, 66 years) who underwent EEG because of new-onset altered consciousness state at a median 5 days from admission; 42 patients developed delirium (46%). Burst-suppression (10 vs 0%, p = .02), rhythmic/periodic patterns (43% vs 22%, p = .03) and epileptiform activity (7 vs 0%, p = .05) were more frequent in delirious versus non-delirious patients. The presence of at least one of these abnormal EEG findings (32/91 patients; 35%) was associated with a significant increase in the likelihood of delirium (42 vs 15%, p = .006). Cumulative dose of sedatives and analgesics, as well as all other EEG characteristics, did not differ significantly between the two groups. In mechanically ventilated non-neurological critically ill patients with new-onset alteration of consciousness, EEG showing burst-suppression, rhythmic or periodic patterns, or seizures/status epilepticus indicate an increased risk of ICU delirium

Cardiogenic shock due to reverse takotsubo syndrome triggered by multiple sclerosis brainstem lesions: a case report and mini review

BackgroundTakotsubo syndrome (TTS) is mainly characterized by chest pain, left ventricular dysfunction, ST-segment deviation on electrocardiogram (ECG) and elevated troponins in the absence of obstructive coronary artery disease. Diagnostic features include left ventricular systolic dysfunction shown on transthoracic echocardiography (TTE) with wall motion abnormalities, generally with the typical “apical ballooning” pattern. In very rare cases, it involves a reverse form which is characterized by basal and mid-ventricular severe hypokinesia or akinesia, and sparing of the apex. TTS is known to be triggered by emotional or physical stressors. Recently, multiple sclerosis (MS) has been described as a potential trigger of TTS, especially when lesions are located in the brainstem.Case summaryWe herein report the case of a 26-year-old woman who developed cardiogenic shock due to reverse TTS in the setting of MS. After being admitted for suspected MS, the patient presented with rapidly deteriorating clinical condition, with acute pulmonary oedema and hemodynamic collapse, requiring mechanical ventilation and aminergic support. TTE found a severely reduced left ventricular ejection fraction (LVEF) of 20%, consistent with reverse TTS (basal and mid ventricular akinesia, apical hyperkinesia). Cardiac magnetic resonance imaging (MRI) performed 4 days later showed myocardial oedema in the mid and basal segments on T2-weighted imaging, with partial recovery of LVEF (46%), confirmed the diagnosis of TTS. In the meantime, the suspicion of MS was also confirmed, based on cerebral MRI and cerebral spinal fluid analyses, with a final diagnosis of reverse TTS induced by MS. High-dose intravenous corticotherapy was initiated. Subsequent evolution was marked by rapid clinical improvement, as well as normalization of LVEF and segmental wall-motion abnormalities.ConclusionOur case is an example of the brain-heart relationship: it shows how neurologic inflammatory diseases can trigger a cardiogenic shock due to TTS, with potentially serious outcomes. It sheds light on the reverse form, which, although rare, has already been described in the setting of acute neurologic disorders. Only a handful of case reports have highlighted MS as a trigger of reverse TTS. Finally, through an updated systematic review, we highlight the unique features of patients with reversed TTS triggered by MS

No Impact of Body Mass Index on Outcome in Stroke Patients Treated with IV Thrombolysis BMI and IV Thrombolysis Outcome.

The impact of excess body weight on prognosis after stroke is controversial. Many studies report higher survival rates in obese patients ("obesity paradox"). Recently, obesity has been linked to worse outcomes after intravenous (IV) thrombolysis, but the number and sample size of these studies were small. Here, we aimed to assess the relationship between body weight and stroke outcome after IV thrombolysis in a large cohort study. In a prospective observational multicenter study, we analyzed baseline and outcome data of 896 ischemic stroke patients who underwent IV thrombolysis. Patients were categorized according to body mass index (BMI) as underweight (<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-34.9 kg/m2) or severely obese (>35 kg/m2). Using uni- and multivariate modeling, we assessed the relationship of BMI with favorable outcome (defined as modified Rankin Scale 0 or 1) and mortality 3 months after stroke as well as the occurrence of symptomatic intracerebral hemorrhages (sICH). We also measured the incidence of patients that had an early neurological improvement of >40% on the National Institutes of Health Stroke Scale (NIHSS) after 24 hours. Among 896 patients, 321 were normal weight (35.8%), 22 underweight (2.5%), 378 overweight (42.2%), 123 obese (13.7%) and 52 severely obese (5.8%). Three-month mortality was comparable in obese vs. non-obese patients (8.1% vs. 8.3%) and did not differ significantly among different BMI groups. This was also true for favorable clinical outcome, risk of sICH and early neurological improvement on NIHSS at 24 hours. These results remained unchanged after adjusting for potential confounding factors in the multivariate analyses. BMI was not related to clinical outcomes in stroke patients treated with IVT. Our data suggest that the current weight-adapted dosage scheme of IV alteplase is appropriate for different body weight groups, and challenge the existence of the obesity paradox after stroke

The role of electroencephalography in the early diagnosis of non-convulsive status epilepticus in elderly patients with acute confusional state: Two possible strategies?

Non-convulsive status epilepticus (NCSE) can pose considerable diagnostic challenges, especially in the elderly, because of the wide differential diagnosis with common underlying causes of acute confusional state in this age group. We reviewed the proposed electroencephalography (EEG) strategies to improve the diagnostic yield of non-convulsive status epilepticus in the elderly population. Specifically, a debated topic of clinical relevance is the exact role of the EEG in the early diagnosis of NCSE in the elderly. Two EEG strategies have been proposed to improve the diagnostic yield of NCSE: emergent abbreviated EEG (EAEEG) recordings with reduced montages, and continuous EEG (CEEG) monitoring. Both approaches appear to be potentially advantageous, but at the same time subject to intrinsic limitations. Our literature review found initial evidence that the diagnostic yield for NCSE of prolonged EEG recordings is superior to routine EEGs. Further research is needed to confirm these preliminary findings and to explore strategies to improve the feasibility of a more widespread use of prolonged recordings within acute clinical settings

ECONOMICS AND DURABILES PAVEMENTS AT HILLIES FORESTS OF GREECE

Η ΟΔΟΣΤΡΩΣΙΑ ΤΩΝ ΔΑΣΙΚΩΝ ΔΡΟΜΩΝ ΣΑΝ ΠΟΛΥΔΑΠΑΝΟ ΕΡΓΟ ΥΠΟΔΟΜΗΣ ΑΠΑΙΤΕΙ ΣΧΕΔΙΑΣΗ ΤΗΣ ΟΙΚΟΝΟΜΙΚΗΣ ΜΕΛΕΤΗΣ ΤΩΝ ΠΑΡΑΓΟΝΤΩΝ Α) ΑΝΤΟΧΗ ΕΔΑΦΟΥΣ, Β) ΚΥΚΛΟΦΟΡΙΑΚΟΥ ΦΟΡΤΟΥ, Γ) ΤΟΠΙΚΟΥ ΠΑΡΑΓΟΝΤΑ, Δ) ΠΟΣΟΤΗΤΟΣ ΜΕΤΑΦΕΡΟΜΕΝΗΣ ΞΥΛΕΙΑΣ, Ε) ΣΥΝΘΕΣΗ ΚΥΚΛΟΦΟΡΙΑΣ. ΣΤΗΝ ΔΙΑΤΡΙΒΗ ΚΑΤΟΠΙΝ ΜΕΛΕΤΗΣ ΤΩΝ ΠΑΡΑΠΑΝΩ ΠΑΡΑΓΟΝΤΩΝ ΔΙΑΡΘΡΩΘΗΚΑΝ ΕΞΙΣΩΣΕΙΣ ΚΑΙ ΣΧΗΜΑΤΙΣΘΗΚΑΝ ΝΟΜΟΓΡΑΦΗΜΑΤΑ ΠΟΥ ΔΙΝΟΥΝ ΤΟΣΟ ΤΟ ΠΑΧΟΣ ΤΟΥ ΑΝΘΕΚΤΙΚΟΥ ΟΔΟΣΤΡΩΜΑΤΟΣ ΑΛΛΑ ΚΑΙ ΤΟ ΕΙΔΟΣ ΤΟΥ ΟΙΚΟΝΟΜΙΚΟΤΕΡΟΥ ΟΔΟΣΤΡΩΜΑΤΟΣ ΓΙΑ ΔΙΑΦΟΡΕΣ ΠΟΣΟΤΗΤΕΣ ΜΕΤΑΦΕΡΟΜΕΝΗΣ ΞΥΛΕΙΑΣ ΣΕ ΕΔΑΦΗ ΜΕ ΔΙΑΦΟΡΕΣ ΤΙΜΕΣ ΑΝΤΟΧΗΣ ΤΟΥΣ CBR

Extended EEG and non-convulsive status epilepticus: Benefit over routine EEG?

EEG monitoring is increasingly used in critically ill patients, but impact on clinical outcome remains unclear. We aimed to investigate the benefit of repeated extended EEG in the prognosis of patients with non-convulsive status epilepticus (SE). We retrospectively collected 29 consecutive patients with non-convulsive SE without coma, who underwent repeated extended EEG between 2013 and 2015. We compared these patients with an historical age-matched group of 58 patients managed between 2011 and 2013 with routine EEG only. We excluded patients treated with therapeutic coma for SE treatment. Outcome at hospital discharge was categorized as return to baseline conditions, new disability, and death. Severity of SE was similar in the two groups, with similar proportion of potential fatal etiologies (58% in the extended EEG group vs 60%, P=.529), similar STESS scores (median was three in both groups, P=.714), and comparable acute hospitalization duration (median of 15 vs 11 days, P=.131). The extended EEG group received slightly more anti-epileptic drugs (median was three in both groups, P=.026). Distribution of the outcome categories at hospital discharge was similar (P=.129). Extended EEG used for the management of non-convulsive status epilepticus does not seem to improve clinical outcome, but is associated with a higher number of prescribed anti-epileptic drugs. The benefit of continuous EEG monitoring in non-convulsive SE without coma SE should be addressed through a randomized trial