Common neurologic emergencies for nonneurologists: When minutes count

Neurologic emergencies arise frequently and, if not diagnosed and treated quickly, can have devastating results, with high rates of long-term disability and death. Prompt recognition is an important skill. This article provides detailed analyses of acute stroke, subarachnoid hemorrhage, status epilepticus, and other neurologic emergencies for physicians who are not neurologists

Continuous Qualitative Electroencephalography as a Noninvasive Neuromonitor

Intracranial pressure (ICP) monitoring frequently guides key decisions in the management of diseases causing intracranial hypertension. Although typically measured by invasive means, contraindications may leave the clinician with little recourse for dynamic ICP evaluation—particularly when the patient’s mental status is compromised. We describe here a healthy 18-year-old woman who subacutely progressed to coma due to diffuse cerebral venous sinus thrombosis. Heparinization precluded the use of invasive ICP monitoring, and electroencephalography (EEG) was used novelly as a surrogate ICP monitor. She responded well to anticoagulation and hyperosmolar therapy guided by qualitative EEG and was later discharged with a nearly normal neurologic examination. She was found to have Salmonella bacteremia, heterozygous prothrombin and factor V Leiden mutations, and hemoglobin H disease

Posttraumatic Stress Symptoms Among COVID-19 Survivors After Hospitalization

Limited data are available on posttraumatic stress symptoms (PTSS) among COVID-19 survivors. This study aimed to contribute to this knowledge base.PTSS among COVID-19 survivors who had been hospitalized were investigated. Patients were identified as COVID-19 positive at hospital admission. COVID-19 survivors were surveyed with the Posttraumatic Stress Disorder Checklist (PCL-5) between March and October 2020 at 5- and 12-month postdischarge follow-up points.Of 411 patients, 331 (81%) survived to hospital discharge. Of these survivors, 83 (25%) completed the PCL-5 at the 5-month follow-up. Of those patients, 12 (14%) screened positive for PTSS. At the 12-month follow-up, four of eight patients remained PTSS positive. Mean age of follow-up participants was 62±15 years; 47% were women, 65% were White, and 63% were Hispanic. PTSS-positive patients were predominantly non-White (67% vs. 30%, p=0.02), and although the differences were not statistically significant, these patients tended to be younger (56 vs. 63 years, p=0.08) and have shorter intensive care unit stays (2.0 vs. 12.5 days, p=0.06). PTSS-positive and PTSS-negative groups did not differ significantly in prehospitalization neurological diagnoses (11% vs. 8%), psychiatric diagnoses (17% vs. 21%), and intensive care admission status (25% vs. 25%). More patients in the PTSS-positive group had returned to the emergency department (50% vs. 14%, p<0.01) and reported fatigue at follow-up (100% vs. 42%, p<0.001). In the multivariate logistic regression model, non-White race (OR=11, 95% CI=2-91) and returning to the emergency department (OR=19, 95% CI=3-252) were associated with PTSS-positive status.PTSS were twice as common among hospitalized COVID-19 survivors than among those in the general population

Abstract P397: Outcomes in Acute Ischemic Stroke Patients Presenting With Impaired Level of Consciousness

Background: Impaired level of consciousness (LOC) on presentation after acute ischemic stroke (AIS) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and their trends after AISby the LOC on stroke presentation. Methods: We studied 238,989 cases with AIS in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, stroke severity, location, hospital size and teaching status. Results: At stroke presentation, 32,861 (14%) cases had impaired LOC (mean age 77, 54% women, 60 white%, 19% Black, 16% Hispanic). Compared to cases with preserved LOC, impaired cases were older (77 vs. 72 years old), more women (54% vs. 48%), had more comorbidities, greater stroke severity on NIHSS ≥ 5 (49% vs. 27%), higher WLST rates (3% vs. 0.6%), and greater in-hospital mortality rates (9% vs. 3%). In our adjusted model however, no significant association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.7, 95%CI 0.6-0.8, p<0.0001) and more likely to ambulate independently (OR 0.7, 95%CI 0.6-0.9, p=0.001). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all irrespective of LOC status. Conclusion: In this large multicenter registry, AIS cases presenting with impaired LOC had more severe strokes at presentation. Although LOC was not associated with significantly worse in-hospital morality, it was associated with higher rates of WLST and more disability among survivors. Future efforts should focus on biomarkers of LOC that discriminates the potential for early recovery and reduced disability in acute stroke patients with impaired LOC

Abstract P436: Outcomes in Intracerebral Hemorrhage Patients Presenting With Impaired Level of Consciousness

Background: Impaired level of consciousness (LOC) on presentation after intracerebral hemorrhage (ICH) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and trends after ICH by the LOC status on presentation. Methods: We studied 37,613 cases with ICH in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, ICH severity, hospital size and teaching status. Results: At stroke presentation, 12,272 (33%) cases had impaired LOC (mean age 72, 49% women, 61 white%, 20% Black, 14% Hispanic). Compared to cases with preserved LOC, LOC case were older (72 vs. 70 years old), more women (49% vs. 45%), more likely to have aphasia (38% vs. 16%), had lower GCS score (9 vs. 15), had greater ICH score (3 vs. 1), greater WLST rates (41% vs. 18%), and had greater in-hospital mortality rates (32% vs. 12%). In our adjusted model, no association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.4, 95%CI 0.2-0.9, p=0.03) and more likely to ambulate independently (OR 1.6, 95%CI 1.1-2.4, p=0.02). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all, regardless of the LOC status. Conclusion: In this large multi-center registry, a third of ICH cases presents with impaired LOC. Although LOC was not associated with significantly more in-hospital morality, LOC was associated with had higher rates of WLST and more disability at discharge. Future efforts should focus on biomarkers of LOC that detect early recovery and reduced disability in ICH patients with impaired LOC

Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness

Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1-4.3], <0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4], <0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229], <0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate. In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST

Covert Tracking to Visual Stimuli in Comatose Patients With Traumatic Brain Injury

This study investigated video eye-tracking (VET) in comatose traumatic brain injury (TBI) patients.: We recruited healthy participants and unresponsive TBI patients. We surveyed the patients' clinicians on whether the patient was tracking and performed the Coma Recovery Scale Revised (CRS-R). We recorded eye movements in response to motion of a finger, a face, a mirror, and an optokinetic stimulus using VET glasses. Patients were classified as "covert tracking" (tracking on VET only), and "overt tracking" (VET and clinical exam). The ability to obey commands was evaluated at 6-month follow-up.: We recruited 20 healthy participants and 10 TBI patients. The use of VET was feasible in all participants and patients. Two patients demonstrated "covert tracking" (CRS-R of 6, 8), two demonstrated "overt tracking" (CRS-R 22, 11), and six patients had "no tracking" (CRS-R 8, 6, 5, 7, 6, 7). Five of 56 (9%) of tracking assessments were missed on clinical exam. All patients with tracking recovered consciousness at follow-up while only 2 out of 6 patients without tracking recovered at follow-up.: VET is a feasible method to measure covert tracking. Future studies are needed to confirm the prognostic value of covert tracking