Rabinstein, Alejandro A.

Background: The expertise required for proper electroencephalography (EEG) setup can make the 10-20 array unwieldy in the hospital setting. There may be a role for an EEG array with reduced leads to improve the efficiency of inpatient practice. Methods: Clips from 100 EEG records, 50 ictal and 50 non-ictal, in adult inpatients from January 1, 2007, to January 1, 2012, were retrospectively reviewed and selected for digital lead reduction and blind review. Two epileptologists reviewed these tracings and documented the presence of seizures and severe disturbance of background. The reduced array included 7 leads spanning the scalp. Three different montages were available. Sensitivity and specificity of the reduced array were calculated using the formal EEG report as the comparison standard. Results: For the detection of any seizure, the reduced array EEG had a sensitivity of 70% and specificity of 96%. Sensitivity for identifying encephalopathic patterns was 62% and specificity was 86%. Focal seizures were more readily identified by the reduced array (20 of 25) than were generalized ictal patterns (13 of 25). Conclusion: The reduced electrode array was insufficiently sensitive to seizure detection. Reducing EEG leads might not be a preferred means of optimizing hospital EEG efficiency.

Background and purposeThe objective of our study was to identify neurological factors associated with poor outcome in adult patients with fulminant bacterial meningitis.MethodsThis was a retrospective review of consecutive adult patients with fulminant bacterial meningitis, defined as meningitis causing coma within 24–48 h of hospitalization, at Mayo Clinic Rochester between January 2000 and November 2010. Functional status was assessed at discharge and upon last follow‐up using the modified Rankin scale (mRS). The primary end‐point was death or new major disability (increase of >2 on the mRS) at last follow‐up.ResultsThirty‐nine patients were identified. Encephalopathy (44%), coma (28%), focal seizures (3%) or a combination of these (26%) were present on admission. The most common pathogen was Streptococcus pneumoniae (57%). All patients were treated with broad spectrum antibiotics and 51% received steroids. Serious systemic complications were seen in 23 patients. Sixteen patients (41%) died during hospitalization. Median mRS at hospital discharge for surviving patients was 3; four patients had new major disability with a mean follow‐up of 11 months. Predictors of death or new major disability included lower Glasgow Coma Scale score at nadir [P = 0.002; age‐ and sex‐adjusted odds ratio (OR) 0.46, 95% confidence interval (CI) 0.28–0.48], longer duration of symptoms before hospitalization (P = 0.045; adjusted OR 2.34, 95% CI 1.02–5.37), abnormal head imaging at presentation (P = 0.008; adjusted OR 9.40, 95% CI 1.78−49.6) and use of intracranial pressure monitoring (P = 0.010, adjusted OR 51.0, 95% CI 2.51−1036).ConclusionMany adult patients who survive hospitalization are able to regain their pre‐morbid level of function. Aggressive management of bacterial meningitis is justified even in comatose adult patients.

Background Limited information is available on the frequency of pulmonary embolism ( PE ) in patients with an acute ischemic stroke ( AIS ). We evaluated clinical characteristics, predisposing factors, and outcomes in AIS patients with PE . Methods and Results We included all AIS patients admitted to participating institutions in the R egistry of the C anadian S troke N etwork. Clinically PE was documented by a physician and confirmed by computed tomography pulmonary angiography within 30 days of the stroke case index. The primary outcome was death or disability at discharge. Secondary outcomes included disposition, length of hospital stay, mortality at 3 months and 1 year. Among 11 287 patients with AIS , PE was found in 89 (0.78%) patients. History of cancer, deep vein thrombosis ( DVT )/ PE , and DVT during the hospitalization were associated with PE . PE was associated with higher risk of death at 30 days (25.8% versus 13.6%; P <0.001), at 1 year (47.2% versus 24.6%; P <0.001), and disability at discharge (85.4% versus 63.6%; P <0.001). Mean length of stay was longer in stroke patients with PE (36 versus 16 days; P =0.001). After adjusting for age, sex, and stroke severity, PE remained associated with lower survival at 30 days and 1 year, and death or disability at discharge ( OR 3.02; 95% CI 1.56 to 5.83). Conclusions In this large cohort study, PE occurred in nearly 1% of AIS patients. PE was more common in patients with severe stroke, history of cancer, previous DVT / PE or acute DVT and associated with lower short‐ and long‐term survival, greater disability, and longer length of stay.

Background and Purpose— The prognostic significance of subarachnoid extension of intracerebral hemorrhage was determined in the INTEnsive blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT2) study. Methods— INTERACT2 was an open randomized controlled trial of early intensive compared with guideline-recommended blood pressure lowering in patients with elevated systolic blood pressure within 6 hours of intracerebral hemorrhage. Independent predictors of death or major disability (scores 3–6 on the modified Rankin Scale) at 90 days were analyzed in logistic regression models. Results— Of 2582 participants, 192 (7%) had subarachnoid extension, which was associated with larger hematoma volumes ( P <0.0001) and higher National Institute of Health Stroke Scale score ( P <0.0001). Subarachnoid extension predicted death or major disability at 90 days (71% versus 53%; unadjusted odds ratio, 2.25; 95% confidence interval, 1.63–3.10; P <0.0001). The association remained significant after adjusting for age, region, lipid-lowering therapy, systolic blood pressure, glucose, location of hematoma, intraventricular extension, and randomized treatment (odds ratio, 2.17; 95% confidence interval, 1.50–3.14; P <0.0001), but not after further adjustment for baseline hematoma volume ( P =0.62). Conclusions— Subarachnoid extension of intracerebral hemorrhage is associated with poor prognosis, which is determined by a larger volume of the underlying intraparenchymal hematoma. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00716079.