The Institute of Medicine report Improving Diagnosis in Health Care called for tools to monitor physicians’ diagnostic process. We addressed this need by developing a tool for clinicians to record and analyze their diagnostic process. The tool was a secure web application in which clinicians used a structured grading system to assess the relative impact of clinical, laboratory, and neuroimaging data for every new diagnosis. Four neurohospitalists used the tool for 6.5 months on a general neurology ward service at a single tertiary-level teaching hospital. Process measures of tool use included number of diagnoses entered, time spent on each data entry, and concordance of diagnoses compared to the medical record. We also aggregated the data across clinicians to examine the average process scores across common inpatient disorders. The 4 clinicians entered 254 new diagnoses that took approximately 3 minutes per patient. In 50 randomly chosen cases, the neurohospitalists’ diagnoses entered into the tool agreed with 92% of diagnoses in the medical record, which was better than the agreement between billing code and medical record diagnoses (74%). The diagnostic process varied across disease categories, showing a spectrum of clinical-dominant (eg, headache), laboratory-dominant (eg, encephalitis), and neuroimaging-dominant (eg, stroke) disorders. This study demonstrated the feasibility of a clinician-driven diagnostic process monitoring system, along with preliminary characterization of the process for common disorders. The tracking of diagnostic process has the potential to promote reflection on clinical practice, deconstruct neurologists’ clinical decision-making, and improve health-care safety.
Recent studies suggest that traumatic brain injury (TBI) is a risk factor for subsequent ischemic stroke, even years after the initial insult. The mechanisms of the association remain unclear. The presence of traumatic subarachnoid hemorrhage (tSAH) may mediate the effect of TBI on long-term stroke risk, as it has previously been linked to short-term vasospasm and delayed cerebral ischemia.
Using administrative claims data, we conducted a retrospective cohort study of acute care hospitalizations. Patients discharged with a first-recorded diagnosis of tSAH were followed for a primary diagnosis of stroke. They were matched to patients with TBI but not tSAH. Cox proportional hazards modeling was used to assess the association between tSAH and stroke while adjusting for covariates.
We identified 40 908 patients with TBI (20 454 patients with tSAH) who were followed for a mean of 4.3 + 1.8 years. A total of 531 had an ischemic stroke after discharge. There was no significant difference in stroke risk between those with tSAH (1.79%; 95% confidence interval [CI] 1.54%-2.08%) versus without tSAH (2.12%; 95% CI 1.83%-2.44%). The same pattern was found in adjusted analyses even when the group was stratified by age-group or by proxies of TBI severity.
Our findings do not support a role of tSAH in mediating the association between TBI and protracted stroke risk. Further study is required to elucidate the mechanisms of long-term increased stroke risk after TBI.
Poststroke functional outcome is critical to stroke survivors. We sought to determine whether adherence to current stroke performance measures is associated with better functional outcome 90 days after an ischemic stroke.
Utilizing the Brain Attack Surveillance in Corpus Christi cohort, we examined adherence to 7 ischemic stroke performance measures from February 2009 to June 2012. Adherence to the measures was analyzed in aggregate using a binary defect-free score and an opportunity score, representing the proportion of eligible measures met. The opportunity score ranges from 0 to 1, with values closer to 1 implying better adherence. Functional outcome, defined by an activities of daily living and instrumental activities of daily living (ADL/IADL) score (range 1-4, higher scores worse), was ascertained at 90 days poststroke. Tobit regression models were fitted to examine the associations between the performance measures and functional outcome, adjusting for demographic and clinical characteristics, including stroke severity.
There were 565 patients with ischemic stroke included in the analysis. The median ADL/IADL score was 2.32 (interquartile range [IQR]: 1.41-3.41). The median opportunity score was 1 (IQR: 0.8-1), and 58.4% of the patients received defect-free care. After adjustment, the opportunity score (P = .67) and defect-free care (P = .92) were not associated with functional outcome.
In this population, adherence to a composite of current stroke performance measures was not associated with poststroke functional outcome after adjustment for other factors. Performance measures that are associated with improved functional outcome should be developed and incorporated into stroke quality measures.
Rapid stroke management has significant implications in patient outcomes. Ipsilateral computed tomography conjugate eye deviation (CT-CED) has been associated with worse outcomes but has never been evaluated as predictive of vascular occlusion. To test the hypothesis that CT-CED is a marker for vascular occlusion, we evaluated patients treated with intravenous tissue plasminogen activator (IV tPA).
We performed a retrospective analysis of patients with acute ischemic stroke treated with IV tPA at a large tertiary care hospital over an 18-month period. A waiver of informed consent was granted. Two examiners evaluated baseline brain CTs blinded to the location of infarct to assess the presence of CT-CED and follow-up imaging for the location of infarct and the presence of intracranial large vessel occlusion. Demographics, initial National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scales (mRSs), and hospital length of stay (LOS) were collected.
Among 104 patients treated with IV tPA, 36 had CT-CED. Inter-rater reliability for CT-CED was excellent ( = 0.97; 95% confidence interval: 0.98-1.0). The CT-CED group was older (69.8 vs 64 years; P = .038), had higher initial NIHSS (14.6 vs 11; P = .01), worse mRS (3.2 vs 2.4; P = .03), and longer LOS (8.4 vs 6.4; P = .05) compared with those without CT-CED. A vascular occlusion in the territory of the infarct was seen in 58% of patients with CT-CED versus 32% without CT-CED (P < .01). Atrial fibrillation (AF) was diagnosed in 61% patients with CT-CED versus 22% without (P < .01).
The CT-CED is associated with higher initial NIHSS, large vessel occlusion, and AF. Prospective studies are needed to ascertain whether CT-CED may be utilized part of a screen for endovascular therapy.
Reducing unplanned hospital readmissions has become a national focus due to the Centers for Medicare and Medicaid Services’ (CMS) penalties for hospitals with high rates. A first step in reducing unplanned readmission is to understand which patients are at high risk for readmission, which readmissions are planned, and how well planned readmissions are currently captured in comparison to patient-level chart review.
We examined all 5455 inpatient neurology admissions over a 2-year period to University of California San Francisco Medical Center and Johns Hopkins Hospital via chart review. We collected information such as patient age, procedure codes, diagnosis codes, all-payer diagnosis-related group, observed length of stay (oLOS), and expected length of stay. We performed multivariate logistic modeling to determine predictors of readmission. Discharge summaries were reviewed for evidence that a subsequent readmission was planned.
A total of 353 (6.5%) discharges were readmitted within 30 days. Fifty-five (15.6%) of the 353 readmissions were planned, most often for a neurosurgical procedure (41.8%) or immunotherapy (23.6%). Only 8 of these readmissions would have been classified as planned using current CMS methodology. Patient age (odds ratio [OR] = 1.01 for each 10-year increase, P < .001) and estimated length of stay (OR = 1.04, P = .002) were associated with a greater likelihood of readmission, whereas index admission oLOS was not.
Many neurologic readmissions are planned; however, these are often classified by current CMS methodology as unplanned and penalized accordingly. Modifications of the CMS lists for potentially planned neurological and neurosurgical procedures and for acute discharge neurologic diagnoses should be considered.
The safety and efficacy of intravenous tissue plasminogen activator (IV tPA) following acute ischemic stroke (AIS) is dependent on its timely administration. In 2014, our Comprehensive Stroke Center designed and implemented a computed tomography-Direct protocol to streamline the evaluation process of suspected patients with AIS, with the aim of reducing door-to-needle (DTN) times. The objectives of our study were to describe the protocol development and implementation process, and to compare DTN times and symptomatic intracranial hemorrhage (sICH) rates before and after protocol implementation.
Data were prospectively collected for patients with AIS receiving IV tPA between January 1, 2010, and May 31, 2015. The DTN times, examined as median times and time treatment windows, and sICH rates were compared pre- and postimplementation.
Two hundred ninety-five patients were included in the study. After protocol implementation, median DTN times were significantly reduced (38 vs 28 minutes; P < .001). The distribution of patients treated in the three time treatment windows described below changed significantly, with an increase in patients with DTN times of 30 minutes or less, and a decrease in patients with DTN times 31 to 60 minutes and over 60 minutes (P < .001). There were two cases of sICH prior to implementation and one sICH case postimplementation.
The implementation of a protocol that streamlined the processing of suspected patients with AIS significantly reduced DTN time without negatively impacting patient safety.
Neurointensive care units have been shown to improve patient outcomes across a variety of neurological and neurosurgical conditions. However, the efficacy of less resource-intensive intermediate-level care units to deliver similar care has not been well studied. The purpose of this study is to evaluate the impact of neurocritical specialist comanagement on patient flow and safety in a neuroscience intermediate-level care unit.
Our intervention consisted of the addition of a physician with critical care experience as well as training in neurology, anesthesiology, or intensive care to a neuroscience intermediate-level care unit to comanage patients alongside neurology and neurosurgery staff during weekday daytime hours. A retrospective analysis was performed on prospectively collected data pertaining to all patients admitted to the unit over a 3-year period, 1 year before our intervention and 2 years after. Patient statistics including wait times to admission, length of stay (LOS), and mortality were reviewed.
Following the intervention, there were significant reductions in wait times to unit admission from both the emergency department and postanesthetic care unit, as well as reductions in the average LOS. No significant safety concerns were identified.
This study has demonstrated that the optimization of a neuroscience intermediate-level care unit involving comanagement of patients by a neurocritical specialist can reduce wait times to admission and lengths of stay, with preserved safety outcomes.
Ischemic stroke is one of the most frequent causes of death in Brazil. Many measures have been taken to reduce this tragic outcome, and one of those is the implementation of stroke units in hospitals. The aim of the present study is to analyze the in-hospital complications for patients with ischemic stroke admitted in a comprehensive stroke ward (CSW) as compared to patients admitted in a mixed rehabilitation ward (MRW).
A retrospective interventional study with historic controls of patients admitted to the Neurology Division between January 2010 and October 2013. Patients admitted between January 2010 and September 2012 were included in the MRW group, and patients admitted from October 2012 until October 2013 were included in the CSW group. Throughout the whole study period, the same team assisted all the patients. Both groups were paired in relation to age and gender. The rate of in-hospital complications, mortality, and independency on discharge were evaluated in both groups.
Each group was comprised of 91 patients. There were no statistically significant differences for any of the risk factors analyzed between the 2 groups nor for outcome measures—in-hospital complications, mortality, and independence on discharge.
The present study demonstrated that in-hospital complications, independence on discharge, and mortality have similar rates in patients admitted to an MRW compared to patients admitted to a CSW, when the same staff provided them with specialized in-hospital care.
Case–control study—Evidence Level 3.
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headache, altered mental status, seizures, or loss of vision. In this study, we report the largest series of PRES coming from Saudi Arabia and explore the etiology, clinical presentation, and outcome. We also report new imaging findings associated with this condition.
We performed a retrospective study of all cases of PRES admitted to King Abdulaziz Medical City, Jeddah, Saudi Arabia, between the years 2005 and 2015. A neurologist reviewed all charts and analyzed the clinical presentations, etiological factors, and outcomes, and a neuroradiologist reviewed the imaging studies. Only patients with clinical and imaging features consistent with PRES were included in the study.
We collected 31 patients who had clinical and radiological features consistent with PRES. Females were more affected than males (18 females and 13 males), and patients’ age ranged from 6 to 95 years, with a mean of 38.3 years. Patients were treated by removing the precipitating causes and treating the underlying conditions. Resolution of neurologic signs occurred within 2 to 3 weeks in all patients.
In our opinion, PRES itself is usually a benign condition with complete recovery if the condition is recognized early and managed appropriately. Although clinical signs are nonspecific, the constellation of symptoms including headache, visual problems, seizures, and altered level of consciousness should suggest the possibility of PRES, especially in high-risk group. Abnormalities on magnetic resonance imaging are often characteristic and may be the first clue to the diagnosis.
Continuous intravenous 3% hypertonic saline (HTS) infusions are commonly used for the management of cerebral edema following severe neurologic injuries. Despite widespread use, data regarding the incidence and predictors of nephrotoxicity are lacking. The purpose of this study was to describe the incidence and identify predictors of acute kidney injury (AKI) in neurocritical care patients administered continuous infusion HTS.
This was an institutional review board–approved, multicenter, retrospective cohort study of patients receiving HTS infusions at 2 academic medical centers. A univariate analysis and multivariable logistic regression were used to identify predictors of AKI. Data regarding AKI were evaluated during treatment with HTS and up to 24 hours after discontinuation.
A total of 329 patients were included in our analysis, with 54 (16%) developing AKI. Those who developed AKI experienced significantly longer stays in the intensive care unit (14.8 vs 11.5 days; P = .006) and higher mortality (48.1% vs 21.9%; P < .001). We identified past medical history of chronic kidney disease (odds ratio [OR]: 9.7, 95% confidence interval [CI]: 1.9-50.6; P = .007), serum sodium greater than 155 mmol/L (OR: 4.1, 95% CI: 2.1-8.0; P < .001), concomitant administration of piperacillin/tazobactam (OR: 3.9, 95% CI: 1.7-9.3; P = .002), male gender (OR: 3.2, 95% CI: 1.5-6.6; P = .002), and African American race (OR: 2.6, 95% CI: 1.3-5.2; P = .007) as independent predictors of AKI.
Acute kidney injury is relatively common in patients receiving continuous HTS and may significantly impact clinical outcomes.
Critical illness myopathy (CIM) and neuropathy are underdiagnosed conditions within the intensive care setting and contribute to prolonged mechanical ventilation and ventilator wean failure and ultimately lead to significant morbidity and mortality. These conditions are often further subdivided into CIM, critical illness polyneuropathy (CIP), or the combination—critical illness polyneuromyopathy (CIPNM). In this review, we discuss the epidemiology and pathophysiology of CIM, CIP, and CIPNM, along with diagnostic considerations such as detailed clinical examination, electrophysiological studies, and histopathological review of muscle biopsy specimens. We also review current available treatments and prognosis. Increased awareness and early recognition of CIM, CIP, and CIPNM in the intensive care unit setting may lead to earlier treatments and rehabilitation, improving patient outcomes.
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.
The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear.
We conducted a cross-sectional survey of members of the Neurocritical Care Society on infection prevention practices for patients with EVDs between April and July 2015.
The survey was completed by 52 individuals (5% response rate). Catheter selection, use of prolonged prophylactic systemic antibiotics (PPSAs), cerebrospinal fluid (CSF) collection policies, location of EVD placement, and performance of routine EVD exchanges varied. Antibiotic-impregnated catheters (AICs) and conventional catheters (CCs) were used with similar frequency, but no respondents reported routine use of silver-impregnated catheters (SICs). The majority of respondents were either neutral or disagreed with the need for PPSA with all catheter types (CC: 75%, AIC: 85%, and SIC: 87%). Despite this, 55% of the respondents reported PPSAs were routinely administered to patients with EVDs at their institutions. The majority (80%) of the respondents reported CSF collection only on an as-needed basis. The EVD placement was restricted to the operating room at 27% of the respondents’ institutions. Only 2 respondents (4%) reported that routine EVD exchanges were performed at their institution.
Practice patterns demonstrate that institutions use varying strategies to prevent ventriculostomy-related infections. Identification and further study of optimum care for these patients are essential to decrease the risk of complications and to aid development of practice standards.
Neurosarcoidosis is a rare but important cause of stroke as it is treatable. Cases reported thus far have primarily been in young people who are relatively healthy. Here we report the case of a 73-year-old woman presenting with recurrent strokes and high-grade intracranial stenosis caused by probable neurosarcoidosis. This is unique as neurosarcoidosis is not usually considered as an etiology for recurrent strokes in our patient’s age-group. We review and categorize published cases of neurosarcoidosis causing stroke and describe a classification scheme for certainty of diagnosis. Given the implications of this diagnosis for secondary stroke prevention, we recommend that neurosarcoidosis be considered in the differential for patients with few vascular risk factors, recurrent strokes refractory to medical treatment, or possible vasculitis even in the elderly patients.
Migraine headache is among the most prevalent neurologic disorders. Status migrainosus often leads to hospitalization, and multiple medications are sometimes required for symptomatic relief. In 2008, neurologists at our institution started using the atypical antipsychotic ziprasidone as an abortive medication for status migrainosus. The Clinical Investigation Data Exploration Repository was used to search for patients admitted to the Barnes-Jewish Hospital inpatient neurology service with diagnoses of "headache" or "migraine." Patients were identified as status migrainosus if they met the International Headache Society criteria for a migraine lasting >72 hours. Clinical records of identified patients were then entered into a secure online database (REDCap). Between 2008 and 2015, a total of 34 patients received 10 to 40 mg of ziprasidone for the treatment of status migrainosus. Among patients who received ziprasidone, headache severity decreased 5.68 ± 3.0 points on a 10-point scale, from admission to discharge. Ziprasidone was the last abortive medication added prior to discharge in 65% of cases. The 30-day readmission rate for migraine headache in patients who received ziprasidone was 12%. Ziprasidone was well tolerated, with side effects limited to a mild dystonic reaction (n = 1), rhinorrhea (n = 1), and a prolonged QTc of 495 milliseconds (n = 1). This observational study suggests that ziprasidone may be a safe, effective abortive medication for the treatment of status migrainosus. Further studies comparing ziprasidone to standard of care are warranted.
We review the case of a young man who developed a constellation of symptoms and signs—bizarre behavior, seizures, abnormal movements, and autonomic instability—that evaded diagnosis at the time of presentation. We use this case to explore the way medical knowledge changes over time. Despite the dramatic advances in our understanding of neurological diseases in recent decades, physicians tend to approach diseases and diagnoses as if they were immutable. Our case reinforces how the diagnosis and treatment of disease are determined by an ever-changing historical context driven by the rapid expansion of medical knowledge. We discuss the implications of this realization and present strategies for navigating the boundaries of knowledge, both in practice and in principle.
We describe video electroencephalography (video-EEG) correlates of transient neurological attacks due to plateau waves—paroxysmal elevations in intracranial pressure—in patients with leptomeningeal metastases. We identified 3 patients with leptomeningeal metastases, intracranial hypertension, and transient neurological attacks captured on video-EEG without evidence of seizures or epileptiform activity. We identified all clinical events on video and reviewed the corresponding EEG data for evidence of abnormalities. All 3 patients had mild to moderate slowing and 2 had frontal intermittent rhythmic delta activity during background EEG recording. There were 33 clinical events recorded and stereotyped for each patient. All 33 events were associated with an increase in delta range slowing of ≥30% compared to the background. This abnormality started ≤2 minutes before the onset of clinical symptoms and persisted for minutes after clinical resolution. This study is the first to carefully describe the electrographic correlates of transient neurological attacks due to plateau waves in patients with leptomeningeal metastasis. Clinical attacks were consistently associated with a possible EEG signature of diffuse delta range slowing. Future studies can validate the sensitivity and specificity of these EEG changes as a prognostic and/or response biomarker in patients with leptomeningeal metastases with or without intracranial hypertension.
A neuron-specific enolase level greater than 33 ng/mL at days 1 to 3 or status myoclonus within 1 day are traditional indicators of poor neurological prognosis in survivors of cardiac arrest. We report the case of a 70-year-old man who received extracorporeal membrane oxygenation following cardiac arrest. Despite having both an elevated neuron-specific enolase concentration of 68 ng/mL and status myoclonus, he made an excellent neurological recovery. The value of traditional markers of poor prognosis such as elevated neuron-specific enolase or status myoclonus has not been systematically validated in patients treated with extracorporeal membrane oxygenation or therapeutic hypothermia. Straightforward application of practice guidelines in these cases may result in tragic outcomes. This case underscores the need for reliable prognostic markers that account for recent advances in cardiopulmonary and neurological therapies.
Cerebral venous thrombosis (CVT) is a relatively rare and understudied disease. We sought to determine the accuracy of International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes to identify CVT.
Retrospective chart review using the electronic medical record (EMR) to identify all patients discharged with CVT following admission or emergency department visit from May 1, 2010 to May 1, 2015 at our center.
We identified 111 patients with an ICD-9 discharge diagnosis code of 325.0 (cerebral sinovenous thrombosis, excluding nonpyogenic cases and cases associated with pregnancy and the puerperium), 437.6 (CVT of nonpyogenic origin), or 671.5 (CVT complicating pregnancy, childbirth, or the puerperium) in any position. Of these 111 patients, 84 (75.7%) had confirmed CVT after EMR review. Searching outpatient and radiology records, we found an additional 24 patients with CVT who were not identified via query of ICD-9 discharge diagnosis codes. The ICD-9 codes 325.0, 437.6, or 671.5 in any position had a combined sensitivity of 77.8% and specificity of 92.7%; in the primary position, they had a sensitivity of 28.7% and specificity of 98.3%.
The ICD-9 codes 325.0, 437.6, and 671.5 can be used to identify CVT with acceptable sensitivity and specificity.
High blood pressure (BP) >140/90 mm Hg is seen in 75% of patients with acute ischemic stroke and in 80% of patients with acute intracerebral hemorrhages and is independently associated with poor functional outcome. While BP reduction in patients with chronic hypertension remains one of the most important factors in primary and secondary stroke prevention, the proper management strategy for acute hypertensive response within the first 72 hours of acute ischemic stroke has been a matter of debate. Recent guidelines recommend clinical trials to ascertain whether antihypertensive therapy in the acute phase of stroke is beneficial. This review summarizes the current data on acute hypertensive response or elevated BP management during the first 72 hours after an acute ischemic stroke. Based on the potential deleterious effect of lowering BP observed in some clinical trials in patients with acute ischemic stroke and because of the lack of convincing evidence to support acute BP lowering in those situations, aggressive BP reduction in patients presenting with acute ischemic stroke is currently not recommended. While the early use of angiotensin receptor antagonists may help reduce cardiovascular events, this benefit is not necessarily related to BP reduction.
Reducing door-to-imaging (DIT) time is a major focus of acute stroke quality improvement initiatives to promote rapid thrombolysis. However, recent data suggest that the imaging-to-needle (ITN) time is a greater source of treatment delay. We hypothesized that language discordance between physician and patient would contribute to prolonged ITN time, as rapidly taking a history and confirming last known well require facile communication between physician and patient.
This is a retrospective analysis of all patients who received tissue plasminogen activator (tPA) in our emergency department between July 2011 and December 2014. Baseline characteristics and relevant time intervals were compared between encounters where the treating neurologist and patient spoke the same language (concordant cases) and where they did not (discordant cases).
A total of 279 patients received tPA during the study period. English was the primary language for 51%, Spanish for 46%, and other languages for 3%; 59% of cases were classified as language concordant and 41% as discordant. We found no differences in median DIT (24 vs 25, P = .5), ITN time (33 vs 30, P = .3), or door-to-needle time (DTN; 58 vs 55, P = .1) between concordant and discordant groups. Similarly, among patients with the fastest and slowest ITN times, there were no differences.
In a high-volume stroke center with a large proportion of Spanish speakers, language discordance was not associated with changes in DIT, ITN time, or DTN time.
The ability of the National Institutes of Health Stroke Scale (NIHSS) score to predict functional outcome in minor stroke is controversial. In this study, we examined the association of itemized NIHSS score with discharge outcome.
We included all patients with final diagnosis of stroke with an NIHSS score of 0 to 5 untreated with thrombolysis enrolled in the "Stroke Warning Information and Faster Treatment" trial. Individual components of the NIHSS score were the primary predictors. Poor outcome was defined as not being discharged home. Logistic regression was used to identify predictors of outcome.
A total of 861 patients met the inclusion criteria; 162 (19%) were not discharged home. In multivariable regression, predictors of discharge other than home were age (odds ratio [OR] = 1.02 per year increase, P < .001) and total NIHSS score (OR per unit increase in the NIHSS = 1.51, P < .001). Motor (OR = 2.32, P < .001), level of consciousness (LOC; OR = 6.62, P = .004), and ataxia (OR = 3.10, P < .001) were also associated with not being discharged home. Motor (area under the curve [AUC] 0.623) appeared to be more predictive of poor outcome than ataxia (AUC 0.569) and LOC (AUC 0.517). The total NIHSS had a fair correlation with discharge outcome (AUC 0.683).
Total and itemized NIHSS components have a fair correlation with outcome in minor stroke highlighting the importance of other measures of stroke severity for clinical trials.
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.
Chronic meningitis of unknown etiology is a vexing illness for patients and clinicians. Identification of the correct pathogen can be challenging and time consuming, leading to delays in appropriate treatment. Although Sporothrix schenckii is a recognized and treatable cause of chronic meningitis, neurologists and infectious diseases physicians may not regularly evaluate for Sporothrix infection. We describe an immunocompetent patient with chronic meningitis who partially responded to empiric fluconazole. Prompted by a recent culture-confirmed case of meningeal sporotrichosis, we tested for S schenckii antibodies from the cerebrospinal fluid, which were positive. His clinical and functional status improved, and the S schenckii antibody titer decreased with itraconazole therapy. Clinicians should consider S schenckii in the differential diagnosis for chronic meningitis, even in immunocompetent patients, particularly when the clinical picture does not respond to standard empiric therapy.
Patients with status migrainosus often need to be admitted due to the severity of their headaches. Their hospitalization is often prolonged due to poor headache control. Large sample studies looking into the factors associated with prolonged length of stay (pLOS) in status migrainosus are lacking.
We utilized the Nationwide Inpatient Sample database to identify 4325 patients with primary discharge diagnosis of status migrainosus. Length of inpatient stay (LOS) of more than 6 days (90th percentile of LOS) was defined as pLOS. Patient demographics, hospital characteristics, mood disorders, anxiety disorder, and common medical comorbidities were identified. Multivariable logistic regression was used to identify factors associated with pLOS.
We found 402 patients with pLOS. Female gender, African American race, mood disorder, obesity, opioid abuse, congestive heart failure, and chronic renal failure were significant independent predictors of pLOS. Median inflation-adjusted cost of hospitalization was USD$3829 (interquartile range: 2419-5809).
We were able to identify several factors associated with pLOS in status migrainosus. Most of the factors we found were similar to those known to increase the prevalence and severity of migraine in the general population. Knowledge of these factors may help physicians identify high-risk patients to institute early migraine abortive and prophylactic treatment in order to shorten the length of hospital stay.
It is important to recognize the signs and symptoms of human African trypanosomiasis (HAT) in order to facilitate early diagnosis and treatment. A 36-year-old man developed encephalitis caused by HAT. This encephalitis can appear many years after well-tolerated systemic infection. The neurologic manifestations developed 7 years after he had emigrated from Cameroon to the United States. We demonstrate the magnetic resonance imaging before, during, and after his treatment with intravenous eflornithine. Clinical signs and symptoms of HAT can be nonspecific and precede abnormalities on magnetic resonance imaging. Human African trypanosomiasis should be considered in the differential diagnosis of patients who have lived in sub-Saharan Africa and have a clinical presentation of subacute encephalitis.
Baclofen is a common medication used as a muscle relaxant and antispasmodic. Baclofen-withdrawal syndrome has many symptoms such as sedation, somnolence, and weakness but can include psychological symptoms. We present a 62-year-old female whose oral baclofen was not continued at a skilled nursing facility after discharge following inpatient surgery that led to the development of altered mental status and respiratory insufficiency necessitating intensive care unit admission. Abrupt cessation of baclofen, no matter the mode of administration to the patient, can lead to baclofen-withdrawal syndrome.
The National Institute of Health Stroke Scale (NIHSS) is rapid and reproducible, a seemingly attractive metric for the documentation of clinical progress in patients presenting with ischemic stroke. Many institutions have adopted it into daily clinical practice. Unfortunately, the scale may not adequately capture all forms of functional change. We evaluate its utility as a measure of recovery in patients treated with intravenous tissue plasminogen activator (IV tPA) for ischemic stroke.
We prospectively evaluated the difference in the rate of improvement based on NIHSS (a ≥4 point change based on previous trials) versus physician-documented subjective and objective measures in 41 patients’ status post IV tPA treatment. The NIHSS 24 hours posttreatment, on discharge, and at follow-up were compared to NIHSS on admission using tests of proportions and McNemar tests of paired data. Secondary analyses were performed defining significant improvement as NIHSS changes of 1 to 3 points.
The mean NIHSS improved from 9 to 6, 24 hours post-tPA. Of the 41 patients, 29 improved by physician documentation, although only 11 of the 29 met the NIHSS criteria (P < .001; McNemar P < .001). On discharge, 20 of the 41 patients met the NIHSS criteria; however, the proportion "better" by physician documentation (71%) remained significantly higher (P = .04; McNemar P = .004). The mean postdischarge follow-up NIHSS was 2. Twenty of the 21 patients improved by documentation versus 16 of the 21 by NIHSS (P = .08, McNemar P = .125). Using NIHSS changes of 1 to 3 increased sensitivity for detecting improvement but remained lower than physician documentation.
The NIHSS has many advantages; however, it may miss functional changes when used in place of a comprehensive neurological examination to measure improvement poststroke.
We describe 2 cases of reversible cerebral vasoconstriction syndrome (RCVS) with refractory headache aborted by intravenous magnesium. Case 1 is a 53-year-old woman with subarachnoid hemorrhage due to RCVS presented with refractory headache and persistent vasospasm, despite aggressive treatment with calcium channel blockers (CCBs) and systemic corticosteroids. Subsequently, she experienced dramatic relief of symptoms with intravenous magnesium therapy. She continued oral maintenance therapy and remained symptom free. Case 2 is a 71-year-old female with bilateral temporo-occipital infarcts due to RCVS, presented with refractory headache and persistent vasospasm on transcranial Doppler (TCD), despite aggressive treatment with CCBs. She experienced dramatic relief of symptoms with intravenous magnesium and resolution of vasospasm on TCD. Magnesium may be beneficial for the treatment of refractory headaches in patients with RCVS. Future studies are needed to determine whether it should be considered as a first-line agent.
Cefepime has been associated with encephalopathy and with nonconvulsive seizure activity, primarily in patients with renal impairment. Here, we report a case of cefepime-associated encephalopathy in a patient with normal renal function with stimulus-induced rhythmic activity seen on electroencephalogram, which resolved on discontinuation of cefepime. We bring this to the attention of the neurohospitalist community, as cefepime is widely used in the hospital setting, and cefepime-related neurotoxicity may go overlooked, especially in patients with normal renal function. Neurologists must recognize drug-related patterns, as the treatment is removing a medication rather than adding an antiepileptic medication.
This is a case of a 52-year-old man with a past medical history of 2 episodes of coital thunderclap headaches as well as recent cocaine, marijuana, and pseudoephedrine use, who presented with sudden, sharp, posterior headache associated with photophobia and phonophobia. His initial magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA) of the head, and magnetic resonance venography (MRV) of the head were all normal as well as a normal lumbar puncture. Given the multiple risk factors for reversible cerebral vasoconstriction syndrome (RCVS), the patient was treated for suspected RCVS, despite the normal imaging. Repeat MRI brain 3 days after hospital admission demonstrated confluent white matter T2 hyperintensities most prominent in the occipital lobes, typical of posterior reversible encephalopathy syndrome (PRES). Repeat MRA of the head 1 day after discharge and 4 days after the abnormal MRI brain showed multisegment narrowing of multiple arteries. This case demonstrates that RCVS may present with PRES on MRI brain and also exemplifies the need to treat suspected RCVS even if imaging is normal, as abnormalities in both the MRI and the MRA may be delayed.
We report a challenging case of cerebral venous sinus thrombosis (multiple etiologic factors) that was complicated by heparin resistance secondary to suspected antithrombin III (ATIII) deficiency. A 20-year-old female previously healthy and currently 8 weeks pregnant presented with worsening headaches, nausea, and decreasing Glasgow Coma Scale/Score (GCS), necessitating mechanical ventilatory support. Imaging showed extensive clots in multiple cerebral venous sinuses including the superior sagittal sinus, transverse, sigmoid, jugular veins, and the straight sinus. She was started on systemic anticoagulation and underwent mechanical clot removal and catheter-directed endovascular thrombolysis with limited success. Complicating the intensive care unit care was the development of heparin resistance, with an inability to reach the target partial thomboplastin time (PTT) of 60 to 80 seconds. At her peak heparin dose, she was receiving >35 000 units/24 h, and her PTT was subtherapeutic at <50 seconds. Deficiency of ATIII was suspected as a possible etiology of her heparin resistance. Fresh frozen plasma was administered for ATIII level repletion. Given her high thrombogenic risk and challenges with conventional anticoagulation regimens, we transitioned to argatroban for systemic anticoagulation. Heparin produces its major anticoagulant effect by inactivating thrombin and factor X through an AT-dependent mechanism. For inhibition of thrombin, heparin must bind to both the coagulation enzyme and the AT. A deficiency of AT leads to a hypercoagulable state and decreased efficacy of heparin that places patients at high risk of thromboembolism. Heparin resistance, especially in the setting of critical illness, should raise the index of suspicion for AT deficiency. Argatroban is an alternate agent for systemic anticoagulation in the setting of heparin resistance.
Patent foramen ovale (PFO) has been proposed as a mechanism for cardioembolic stroke, especially in younger patient populations. Complex PFOs, with tunnel lengths exceeding 8 mm, lead to a higher risk of neurological sequelae than simple PFOs and may also be harder to detect with transthoracic echocardiography (TTE). In this article, we present a 29-year-old woman who, after polypharmacy overdose, developed deep venous thrombosis and multiple pulmonary emboli (PE) and subsequent cardioembolic stroke. Initial TTE showed intact interatrial septum with late appearance of agitated saline in the left atrium after the seventh cardiac cycle. Subsequent transesophageal echocardiography, after treatment of PE with an intravenous thrombolytic (alteplase) and anticoagulation with heparin, showed a complex PFO with a 19-mm overlap of the septum primum and secundum without active flow. It is suggested that this PFO allowed for flow only in the situation of elevated right heart strain with PE, causing cardioembolic stroke and detection of agitated saline in the left atrium on TTE. However, under normal physiological situations, which resumed after treatment of PE with alteplase and heparin, the PFO did not allow for flow. This case demonstrates the potential importance of recognition of complex PFOs in diagnosis and management of cardioembolic stroke.
Poliomyelitis is a highly infectious disease caused by a virus belonging to the Picornaviridae family. It finds a mention even in ancient Egyptian paintings and carvings. The clinical features are varied ranging from mild cases of respiratory illness, gastroenteritis, and malaise to severe forms of paralysis. These have been categorized into inapparent infection without symptoms, mild illness (abortive poliomyelitis), aseptic meningitis (nonparalytic poliomyelitis), and paralytic poliomyelitis. This disease has been associated with crippling deformities affecting thousands of lives throughout the world. Only due to the perseverance and determination of great scientists in 1900s, the genomic structure of the virus and its pathogenesis could be elucidated. Contribution of Salk and Sabin in the form of vaccines—oral polio vaccine (OPV) and the inactivated polio vaccine—heralded a scientific revolution. In 1994, the World Health Organization (WHO) Region of The Americas was certified polio free followed by the WHO Western Pacific Region in 2000 and the WHO European Region in June 2002 of the 3 types of wild poliovirus (types 1, 2, and 3). In 2013, only 3 countries remained polio endemic—Nigeria, Pakistan, and Afghanistan. Global eradication of polio is imperative else the threat of an outbreak will hover forever. Today, all the governments of the world in collaboration with WHO stand unified in their fight against poliomyelitis and the task when achieved will pave the way for eliminating other infections in future.
Neurologic complications of infective endocarditis (IE) are common and frequently life threatening. Neurologic events are not always obvious. The prediction and management of neurologic complications of IE are not easily approached algorithmically, and the impact they have on timing and ability to surgically repair or replace the affected valve often requires a painstaking evaluation and joint effort across multiple medical disciplines in order to achieve the best possible outcome. Although specific recommendations are always tailored to the individual patient, there are some guiding principles that can be used to help direct the decision-making process. Herein, we review the pathophysiology, epidemiology, manifestations, and diagnosis of neurological complications of IE and further consider the impact they have on clinical decision making.
We sought to better understand the potential impact of the burgeoning neurohospitalist model of inpatient care on education of neurology residents and to better define possible roles for "neurohospitalists" in residency education.
We designed a brief qualitative open-ended survey directed toward academic leaders in neurology and distributed it by e-mail to every academic neurology department in the United States and Canada.
Of 83 respondents, 36 (43%) had an active neurohospitalist program and only 10% felt certain they would not have 1 within the next 5 years. All respondents expected to have residents continue to be involved with inpatient care. The main perceived advantage for resident education associated with neurohospitalists was inpatient care expertise, and the main expected disadvantage was decreased exposure to subspecialty attendings. The majority anticipated positive impact on all Accreditation Council for Graduate Medical Education core competencies predominantly based on neurohospitalists’ expertise in the inpatient setting.
The majority of academic neurology departments are expected to have a neurohospitalist program within the next 5 years. There are several perceived advantages and disadvantages to such a program for education of neurology residents. In general, the impact of these programs is expected to improve resident education. Regardless of expectations, neurohospitalists will likely play a prominent role in the education of the next generation of neurologists.
Chronic meningitis is defined as an inflammatory cerebrospinal fluid (CSF) profile that persists for at least 1 month. The presentation often includes headache, nausea, vomiting, cranial neuropathies, symptoms of elevated intracranial pressure, or focal neurologic deficits. The most common etiologies of chronic meningitis fall into 3 broad categories: infectious, autoimmune, and neoplastic. Evaluation of the patient with suspected chronic meningitis should include a detailed history and physical examination as well as repeated CSF diagnostics, serologic studies, and biopsy of the brain or other abnormal tissue (eg, lymph node or lung), when indicated. Early identification of the etiology and rapid treatment are crucial for improving morbidity and mortality, but potential infectious and neoplastic conditions should be excluded prior to empirically starting steroids or immunosuppressive medications.
Although traditional hallucinogenic drugs such as marijuana and lysergic acid diethylamide (LSD) are not typically associated with seizures, newer synthetic hallucinogenic drugs can provoke seizures. Here, we report the unexpected consequences of taking a street-bought hallucinogenic drug thought to be LSD. Our patient presented with hallucinations and agitation progressing to status epilepticus with a urine toxicology screen positive only for cannabinoids and opioids. Using liquid chromatography high-resolution mass spectrometry, an additional drug was found: an amphetamine-derived phenylethylamine called 2,5-dimethoxy-4-chloroamphetamine. We bring this to the attention of the neurologic community as there are a growing number of hallucinogenic street drugs that are negative on standard urine toxicology and cause effects that are unexpected for both the patient and the neurologist, including seizures.
The earliest recorded application of therapeutic hypothermia in medicine spans about 5000 years; however, its use has become widespread since 2002, following the demonstration of both safety and efficacy of regimens requiring only a mild (32°C-35°C) degree of cooling after cardiac arrest. We review the mechanisms by which hypothermia confers neuroprotection as well as its physiological effects by body system and its associated risks. With regard to clinical applications, we present evidence on the role of hypothermia in traumatic brain injury, intracranial pressure elevation, stroke, subarachnoid hemorrhage, spinal cord injury, hepatic encephalopathy, and neonatal peripartum encephalopathy. Based on the current knowledge and areas undergoing or in need of further exploration, we feel that therapeutic hypothermia holds promise in the treatment of patients with various forms of neurologic injury; however, additional quality studies are needed before its true role is fully known.
Intravenous thrombolysis is the standard treatment for acute ischemic stroke (AIS). However, patients with cancer who have stroke are often precluded from therapy because of coagulopathy or recent surgery. Endovascular therapy may be a more suitable recanalization strategy for some patients with cancer and stroke, but no prior detailed reports documenting its use in this population exist. We present a case series from a tertiary care referral center of 2 patients with active systemic cancer who were successfully treated with endovascular therapy for AIS. Both patients had active lung cancer with excellent premorbid functional status and presented with severe AIS from left middle cerebral artery occlusions. Intravenous thrombolysis was deferred because of absolute contraindications. Mechanical embolectomy was performed instead and revascularization was achieved within 5 hours in both patients, resulting in dramatic neurological recoveries—National Institutes of Health Stroke Scale improved from 14 to 0 and from 23 to 3 from admission to discharge, respectively. In conclusion, endovascular therapy may be beneficial for select patients with cancer and AIS who are ineligible for intravenous thrombolysis. However, further studies are needed to determine the safety and efficacy of endovascular therapy in the population with cancer.
In 2011, the Accreditation Council on Graduate Medical Education (ACGME) redefined resident duty hour requirements by reducing in-hospital duty hour requirements for residents in an effort to improve patient care, resident well-being, and resident education. We sought to determine the cost of adoption based on changes made by neurology residency programs and departments due to these requirements.
We surveyed department chairs or residency program directors at 123 ACGME-accredited US adult neurology training programs on programmatic changes and resident expansion, hiring practices, and development of new computer-based resources in direct response to the 2011 ACGME duty hour requirements. Using data from publicly available resources, we estimated respondents’ financial cost of adoption.
In all, 63 responded (51% response rate); 76% were program directors. The most common changes implemented by programs were adding night float systems (n = 31; 49%) and increasing faculty responsibility (n = 26; 41%). In direct response to the requirements, 21 programs applied to ACGME for 40 additional residents, 29 of which were fully covered by institutional funds. In direct response to the requirements, nearly half of the departments (n = 26) hired individuals for a total of 80 hires (or 64 full-time equivalents), most commonly mid-level practitioners. The total estimated cost to responding departments was US $12.7 million or US $201,000 per department annually. When projecting expenses of planned changes for the following year, costs increased to US $360,000 per department, with 5-year costs exceeding US $1 million.
The most recent restriction on resident duty hours comes at substantial cost to neurology departments and residency programs.
A 44-year-old woman presented with recurrent episodes of thunderclap headache. Neurological examination and computed tomography brain imaging were unremarkable. Cerebrospinal fluid findings were consistent with subarachnoid hemorrhage. Computed tomography angiography of the circle of Willis showed multiple areas of segmental vasoconstriction. This finding was confirmed on cerebral catheter angiography, with segmental vasoconstriction involving bilateral internal carotid, posterior cerebral, and external carotid branches. No aneurysm or other vascular abnormality was identified. She received treatment with nimodipine. A selective serotonin reuptake inhibitor, started 4 weeks earlier, was discontinued. Follow-up angiography after 3 months demonstrated complete resolution of the segmental vasoconstriction, confirming the diagnosis of reversible cerebral vasoconstriction syndrome (RCVS). She remained headache free at follow-up. To our knowledge, external carotid artery branch involvement in RCVS has been described only in one previous occasion.
Movement disorders have been reported as rare complications of stroke. The basal ganglia have been implicated in the pathophysiology of most post-stroke dyskinesias. We outline different types of post-stroke myoclonus and their possible pathophysiology. A middle-aged man developed generalized myoclonus after an ischemic stroke in the superior midbrain and subthalamic nuclei. Spontaneous resolution was seen by 72 hours. A lesion to the subthalamic nuclei disrupted the normal thalamic inhibition, which likely led to the involuntary movements seen in our patient. In this case, myoclonus was generalized, which, to the best of our knowledge, has not been reported in the literature as a direct consequence of focal stroke.
Prognostication of patients who remain comatose following successful resuscitation after cardiac arrest has long posed a challenge for the consulting neurologist. With increasing rates of early defibrillation, out-of-hospital cardiopulmonary resuscitation, and expanding use of therapeutic hypothermia, prognostication in hypoxic–ischemic encephalopathy has become an increasingly common consult for neurologists. Much of the data we previously relied upon for prognostication were taken from patients who were not treated with therapeutic hypothermia. In this review, we examine useful prognostic tools and markers, including the physical examination, evaluation of myoclonus, electroencephalogram monitoring, somatosensory-evoked potentials, biochemical markers of neuronal injury, and neuroimaging. Neurologists must avoid overly pessimistic prognostic statements regarding survival, awakening from coma, or future quality of life, as such statements may unduly influence decisions regarding the continuation of life-sustaining treatment. Conversely, continuation of aggressive medical management in a patient without any hope of awakening should also be avoided. Thus, an understanding of the utility and the limitations of these prognostic tools in the era of therapeutic hypothermia is essential.
Transient neurological dysfunction may be associated with uncommon disorders and should prompt consideration of a broad differential diagnosis when assessing patients with episodic symptoms. The most common causes of transient neurological dysfunction include transient ischemic attack (TIA), seizure disorder, and migraine and its variants. However, underlying unusual pathophysiological processes such as brain tumors can also cause transient neurological dysfunction. Here we present a case of a 68-year-old male with oligodendroglial gliomatosis cerebri (OGC) who presented with TIA-like symptoms. Brain magnetic resonance imaging revealed multiple diffuse T2 hyperintensities within the white and gray matter. Magnetic resonance spectroscopy was suggestive of gliomatosis cerebri and was particularly helpful in this case. The diagnosis of OGC was confirmed by histopathology and molecular genetic studies on brain biopsy tissue. In this report, we discuss the clinical and radiological characteristics of OGC and highlight the unusual presentation of this case.
Computerized physician order entry (CPOE) has been promoted as an important component of patient safety, quality improvement, and modernization of medical practice. In practice, however, CPOE affects health care delivery in complex ways, with benefits as well as risks. Every implementation of CPOE is associated with both generally recognized and unique local factors that can facilitate or confound its rollout, and neurohospitalists will often be at the forefront of such rollouts. In this article, we review the literature on CPOE, beginning with definitions and proceeding to comparisons to the standard of care. We then proceed to discuss clinical decision support systems, negative aspects of CPOE, and cultural context of CPOE implementation. Before concluding, we follow the experiences of a Chief Medical Information Officer and neurohospitalist who rolled out a CPOE system at his own health care organization and managed the resulting workflow changes and setbacks.
Chronic paroxysmal intracranial hypertension leading to syncope is a phenomenon not reported previously in patients with refractory cerebral venous sinus thrombosis. We report a case of paroxysmal intracranial hypertension leading to syncopal episodes in a patient with idiopathic autoimmune hemolytic anemia and venous sinus thrombosis. This case demonstrates that intermittent elevations in intracranial pressure can lead to syncope in patients with venous sinus thrombosis and emphasizes the importance of considering this potentially treatable etiology of syncopal episodes.
We sought to determine the current practices and plans for departmental hiring of neurohospitalists at academic medical centers and to identify the core features of a neurohospitalist training program.
We surveyed department chairs or residency program directors at 123 Accreditation Council for Graduate Medical Education (ACGME)-accredited US adult neurology training programs.
Sixty-three(51% response rate) responded, 76% of whom were program directors. In all, 24 (38%) academic neurology departments reported employing neurohospitalists, and an additional 10 departments have plans to hire neurohospitalists in the next year. In all, 4 academic neurology departments have created a neurohospitalist training program, and 10 have plans to create a training program within the next 2 years. Hospitals were the most frequent source of funding for established and planned programs (93% of those reporting). Most (n = 39; 65%) respondents felt that neurohospitalist neurology should be an ACGME-accredited fellowship. The highest priority neurohospitalist training elements among respondents included stroke, epilepsy, and consult neurology as well as patient safety and cost-effective inpatient care. The most important procedural skills for a neurohospitalist, as identified by respondents, include performance of brain death evaluations, lumbar punctures, and electroencephalogram interpretation.
Neurohospitalists have emerged as subspecialists within neurology, growing both in number and in scope of responsibilities in practice. Neurohospitalists are in demand among academic departments, with many departments developing their existing presence or establishing a new presence in the field. A neurohospitalist training program may encompass training in stroke, epilepsy, and consult neurology with additional focus on patient safety and cost-effective care.
Neurology residency training programs have been profoundly impacted by recent changes in resident duty hours, workloads, and supervisory requirements. In response, many programs have adopted a night float coverage system to minimize the requirements for overnight call. The majority involves residents working a block of night shifts in what is typically a service-oriented rotation. Recently, concerns have arisen regarding the impact of this design on resident education and patient care. We have developed a novel on-site nighttime neurohospitalist model for the explicit purpose of steepening the initial learning curve for neurology residents in an effort to rapidly improve their neurological skills and, in conjunction, overnight patient care. We surveyed residents after the initiation of this system to assess their perception of the impact of direct overnight supervision on education and patient care.
As part of ongoing quality improvement efforts, surveys were administered to neurology house staff at a tertiary academic medical center after they had completed service on the night float rotation both with and without an attending in the hospital using a retrospective pre/postdesign.
There was a robust positive impact on resident’s perception of overall quality, educational value, and clinical quality on the night float rotation with an attending on-site. Despite an overall perception that their autonomy was maintained, residents believed barriers to contact the attending were lower, and attending interaction during critical decision making was more frequent.
Direct overnight supervision by a neurohospitalist enhances the educational value and care quality on overnight resident rotations.
Delirium is an acute change in awareness and attention and is common, morbid, and costly for patients and health care systems. While hyperactive delirium is easily identifiable, the hypoactive form is more common and carries a higher mortality. Hospital systems to address delirium should consist of 3 critical steps. First, hospitals must identify patients who develop or are at intermediate or high risk for delirium. Delirium risk may be assessed using known patient-based and illness-based risk factors, including preexisting cognitive impairment. Delirium diagnosis remains a clinical diagnosis that requires a clinical assessment that can be structured using diagnostic criteria. Hospital systems may be useful to efficiently allocate delirium resources to prevent and manage delirium. Second, it is crucial to develop a systematic approach to prevent delirium using multimodal nonpharmacologic delirium prevention methods and to monitor all high-risk patients for its occurrence. Tools such as the modified Richmond Agitation and Sedation Scale can aid in monitoring for changes in mental status that could indicate the development of delirium. Third, hospital systems can utilize established methods to assess and manage delirium in a standardized fashion. The key lies in addressing the underlying cause/causes of delirium, which often involve medical conditions or medications. With a sustained commitment, standardized efforts to identify and prevent delirium can mitigate the long-term morbidity associated with this acute change. In the face of changes in health care funding, delirium serves as an example of a syndrome where care coordination can improve short-term and long-term costs.
Palinacousis is an auditory illusion consisting of perseveration or echoing of an external auditory stimulus after it has ceased. This rare clinical symptom has been reported in ictal (seizure), postictal, and nonictal states, and causative lesions have been most consistently found in or near the temporal lobes. It is distinct from the auditory hallucinations seen in psychiatric illness. We report the case of a 61-year-old man who experienced several days of palinacousis while undergoing treatment for newly diagnosed metastatic lung adenocarcinoma. Palinacousis was presumed to be triggered by intracranial metastases near the auditory cortex. An electroencephalogram showed bilateral theta slowing over the left greater than right temporal lobes without epileptiform activity. Palinacousis remitted with corticosteroid and whole brain radiation therapy.
Neurological diseases are prevalent in the general population, and the neurohospitalist has an important role to play in the preoperative planning for patients with and at risk for developing neurological disease. The neurohospitalist can provide patients and their families as well as anesthesiologists, surgeons, hospitalists, and other providers guidance in particular to the patient’s neurological disease and those he or she is at risk for. Here we present considerations and guidance for the neurohospitalist providing preoperative consultation for the neurological patient with or at risk of disturbances of consciousness, cerebrovascular and carotid disease, epilepsy, neuromuscular disease, and Parkinson disease.
Notably absent from current practice guidelines for common neurologic diseases as stroke and seizure is the revised Centers for Disease Control (CDC) recommendation for human immunodeficiency virus (HIV) testing of all clinical encounters. During a 9-month period 2 patients with treatable stroke mimics related to HIV type 1 infection were misdiagnosed resulting in delay in beginning antiretroviral therapy and increased cost and morbidity. This study was conducted to determine the frequency of HIV-1 screening in our stroke center population and consider the implications of such testing on neurologic disease. We surveyed our stroke center database to determine the frequency of HIV screening in ischemic strokes from January 2005 through May 2011. Of 2806 ischemic strokes, 27 (0.96%) patients were HIV-tested during the 6.5-year study period. We suggest that incorporating the CDC recommendations for HIV screening into neurology practice guidelines can impact diagnosis and treatment of unsuspected HIV-related neurologic disease with reduction in cost of care and morbidity.
In this 2 part series, analysis of the risk stratification tools that are available and definition of the scope of the problem and potential solutions through a review of the literature is presented. A systematic review was used to identify articles for risk stratification and interventions. Three risk stratification systems are discussed, STRATIFY, Morse Fall Scale, and the Hendrich Fall Risk Model (HFRM). Of these scoring systems, the HFRM is the easiest to use and score. Predominantly, multifactorial interventions are used to prevent patient falls. Education and rehabilitation are common themes in studies with statistically significant results. The second article presents a guide to implementing a quality improvement project around hospital falls. A 10-step approach to Plan-Do-Study-Act (PDSA) cycles is described. Specific examples of problems and analysis are easily applicable to any institution. Furthermore, the sustainability of interventions and targeting new areas for improvement are discussed. Although specific to falls in the hospitalized patient, the goal is to present a stepwise approach that is broadly applicable to other areas requiring quality improvement.
To expand the adverse events associated with metronidazole to include nonconvulsive status epilepticus (NCSE).
Observational single case report of a rare association.
Hospitalized lung transplant recipient treated with metronidazole for prevention of infection.
A 56-year-old man with systemic symptoms, peripheral neuropathy, generalized seizure, and a subsequent acute deterioration of mental status due to NCSE.
Administration of midazolam was successful in terminating status epilepticus.
Abrupt termination of NCSE was evident on continuous bedside electroencephalogam associated with clinical resolution of mental status.
Recovery occurred from NCSE eventually deteriorating to a fatal outcome.
Metronidazole may be associated with successfully treated NCSE.