Altered Level Of Consciousness Research Articles

Cerebral venous thrombosis: a practical review.

The evolution of the Coronavirus Disease-2019 pandemic and its vaccination raised more attention to cerebral venous thrombosis (CVT). Although CVT is less prevalent than arterial stroke, it results in larger years of life lost. CVT is more common in women and young patients. Predisposing factors are categorized as transient factors such as pregnancy, puerperium, oral contraceptive pills, trauma, and dehydration; and permanent factors such as neoplastic, vasculitic, thrombophilic, hematologic conditions, infectious causes such as severe acute respiratory syndrome coronavirus-2 infection and HIV. The most common manifestations are headache, seizures, focal neurologic deficits, altered level of consciousness, and cranial nerve palsies. The most common syndromes are stroke-like, raised-intracranial-pressure (ICP), isolated-headache, and encephalopathy, which may have overlaps. Diagnosis is mostly based on computed tomography, magnetic resonance imaging, and their respective venous sequences, supported by blood results abnormalities such as D-dimer elevation. Treatment includes the prevention of propagation of current thrombus with anticoagulation (heparin, or low molecular weight heparinoids and then warfarin, or direct oral anticoagulants), decreasing ICP (even by decompressive craniotomy), and treatment of specific underlying diseases.

Ureaplasma-Induced Hyperammonemia Syndrome - an Acute Complication Post Allogeneic Stem Cell Transplant

Hyperammonemia syndrome is characterized by elevated serum ammonia levels and neurological dysfunction due to cerebral encephalopathy, andcauses lethargy, confusion, hyperventilation, seizures, death. In solid organ transplantation, hyperammonemia syndrome has been reported as a potentially fatal complication secondary to Ureaplasma infection ( Ureaplasma urealyticum or parvum). We present a patient with acute lymphoblastic leukemia (ALL) who underwent allogeneic stem cell transplant (HSCT) and developed hyperammonemia syndrome during systemic infection with Ureaplasma urealyticum. A 32-year-old female with B-ALL received a haploidentical HSCT complicated by stage II acute GvHD of the gut and skin. During her hospital course, on Day +43, cellulitis of the right arm was diagnosed and treated empirically with amoxicillin-clavulanate on discharge. She presented back to the hospital on Day +53 with bilateral elbow pain and cellulitis. She had no focal neurological deficits initially but became increasing drowsy with dilated pupils. She had no episodes of sustained fever throughout her hospitalization. Empiric antimicrobial coverage with Meropenem and Vancomycin was given, and she was intubated and admitted to the ICU all on the same day. CT head was normal, and blood cultures and lumbar puncture were negative. She developed status epilepticus and her ammonia level increased to >1500 μmol/L on Day +57. Liver function, renal function and extended electrolytes remained within normal limits. MRI was consistent with hyperammonemic encephalopathy, prompting initiation of intermittent hemodialysis, lactulose, Rifaximin, and L-carnitine. EEG revealed no discernible rhythms, and intensive life support was discontinued on Day +61. PCR testing of preserved lung tissue confirmed Ureaplasma urealyticum as the likely cause. Ureaplasma infections can be a serious complication of HSCT. The hydrolysis of urea by U reaplasma leads to elevated serum ammonia levels when systemic infections occur in immunocompromised patients. HSCT patients often have hypogammaglobulinemia due to conditioning and immunosuppressive therapies with a reduced ability to neutralize Ureaplasma. The role of neutrophil in controlling Ureaplasma is limited, as antibody-mediated defence is the sole mechanism of protection. Other contributing factors that can exacerbate hyperammonemia include Valproic acid, severe liver disease, and TPN. Ureaplasma is challenging to diagnose due to limited growth on standard culture medium PCR testing is required for diagnosis and was the method of detection in our reported case. Numerous cases in non-HSCT immunocompromised populations have reported soft tissue infections involving Ureaplasma species, indicating a possible source for infection in the current case. Although there are no other reported cases of cellulitis and Ureaplasma infection in HSCT, a previous case with polyarthritic involvement may be mechanistically similar. A literature review was completed with results presented in Table 1 outlining details of reported cases with confirmed Ureaplasma infection post-HSCT. The cases were quite heterogenous although two of the cases were treated for Non-Hodgkin's Lymphoma where they were heavily pretreated with agents targeting B-Cells and immunoglobulin production. Empirical doxycycline should be considered first line due to the Ureaplasma resistance to other agents such as Azathioprine. Beta-lactam antibiotics and vancomycin have limited efficacy as Ureaplasma's does not have a cell wall. Adjunct therapies to reduce ammonia production and increase elimination should also be considered. Ureaplasma should be considered in immunocompromised patients in the context of fever of unknown origin and altered level of consciousness, especially if rising serum ammonia levels and soft tissue infections is present. The overall 50% mortality associated with the six cases presented demonstrates the significant risk associated with the infection.

Abstract 106: CHANTER Syndrome: A Case Report Of A 59 Year Old Man With Positive Outcome

Introduction Cerebellar, Hippocampal, and Basal Nuclei Transient Edema with Restricted Diffusion (CHANTER) syndrome was first described in 2019 [1] as a pattern of radiographic findings that are distinct from ischemic, anoxic, or toxic brain injury. Pathophysiology is still uncertain, but some proposed theories include a primary metabolic etiology or a mitochondrial failure of gray matter. Clinically, patients typically present with altered level of consciousness. Radiographically, diffusion weighted imaging shows restriction in the bilateral hippocampi, bilateral cerebelli, and basal nuclei. The cerebral cortex, thalamus, and subcortical white matter are usually spared. Despite the morbid clinical picture on presenation, positive outcomes were reported with early intervention. We describe a case of CHANTER syndrome in a 59 year old man with history of illicit substance abuse. Methods Case report with electronic medical record review. Results 59‐year‐old man with history of illicit substance abuse including cocaine, opioid, and phencyclidine presented to the hospital after being found down at a drug store. Patient did not respond to Naloxone and was eventually intubated due to respiratory compromise. Non‐contrast CT head showed hypoattenuation of the bilateral cerebellar hemispheres with mild effacement of the fourth ventricle. MRI brain showed diffusion signal abnormalities with corresponding T2 FLAIR hyperintensities in the bilateral cerebellar hemispheres, bilateral hippocampi, and bilateral basal ganglia with some involvement of the left occipital lobe suggestive of CHANTER syndrome. As vasogenic edema worsened, hydrocephalus ensued requiring administration of hypertonic saline and eventual external ventricular drain (EVD) insertion in the neurocritical care unit. Despite initial improvement in his level of consciousness after the EVD insertion, his intracranial pressure (ICP) continued to increase and midazolam and ketamine infusion drips were added. A fine balance between lowering the ICP and avoiding respiratory suppresion with sedating infusions was maintained. Consecutive MRI brain images over the course of the following 4 weeks of his stay showed decrease of the abnormal diffusion weighted imaging signal along with improvement in his overall mental status and eventual discharge 12 weeks from his initial presentation. Conclusion This case further strengthens the relationship between CHANTER syndrome and illicit substance use as a likely etiology along with other cases in the literature. Aggressive management in the neurocritical care to control vasogenic edema and avoid ICP elevation is essential to give patients the highest chance of recovery. Clinical improvement At least partial reversal of the radiographic findings of CHANTER syndrome can be attained with treatment, however, unclear if complete reversal is possible.

Accidental toluene overdose in a patient with altered level of consciousness and a raised anion gap acidosis of unknown cause.

Accidental toluene overdose in a patient with altered level of consciousness and a raised anion gap acidosis of unknown cause.

Role of Venous Blood Gase (VBG) Analysis in Patient Triage in the Adult Emergency Department

Background: In emergency and critical care settings, can a venous blood gas analysis improve clinical decision-making and patient outcomes? Methods: This is a cross-sectional study, conducted between January and June 2022 at a tertiary hospital in Saudi Arabia. Results: A total of 100 patients were included, using a convenience sample technique. Their mean age was 54 years, and theirmain chief complaints were shortness of breath (30%), abdominal pain (15%), and altered level of consciousness (14%). The venous blood gas (VBG) result was abnormal in 86 patients, and predicted the need for early intervention in 69 patients (69.7%). A significant association was found between patients requiring early intervention and those with an abnormal VBG (p=0.0005). Furthermore, the VBG results changed the Canadian Triage and Acuity Scale (CTAS) level in 32 patients (33.68%). A logistic regression analysis revealed that pre-testing factors such as age, gender, comorbidities, and chief complaints were not predictors of VBG results, the need for early intervention, or altered CTAS level. Conclusion: Our study concludes that VBG analysis can play an important role in patient triage in the emergency department (ED), allowing for earlier intervention and potentially improving outcomes.

EEG spectral slope: A reliable indicator for continuous evaluation of consciousness levels during propofol anesthesia

The level of consciousness undergoes continuous alterations during anesthesia. Prior to the onset of propofol-induced complete unconsciousness, degraded levels of behavioral responsiveness can be observed. However, a reliable index to monitor altered consciousness levels during anesthesia has not been sufficiently investigated. In this study, we obtained 60-channel EEG data from 24 healthy participants during an ultra-slow propofol infusion protocol starting with an initial concentration of 1 μg/ml and a stepwise increase of 0.2 μg/ml in concentration. Consecutive auditory stimuli were delivered every 5 to 6 s, and the response time to the stimuli was used to assess the responsiveness levels. We calculated the spectral slope in a time-resolved manner by extracting 5-second EEG segments at each auditory stimulus and estimated their correlation with the corresponding response time. Our results demonstrated that during slow propofol infusion, the response time to external stimuli increased, while the EEG spectral slope, fitted at 15–45 Hz, became steeper, and a significant negative correlation was observed between them. Moreover, the spectral slope further steepened at deeper anesthetic levels and became flatter during anesthesia recovery. We verified these findings using an external dataset. Additionally, we found that the spectral slope of frontal electrodes over the prefrontal lobe had the best performance in predicting the response time. Overall, this study used a time-resolved analysis to suggest that the EEG spectral slope could reliably track continuously altered consciousness levels during propofol anesthesia. Furthermore, the frontal spectral slope may be a promising index for clinical monitoring of anesthesia depth.

Transitional meningioma benign who grade 1 tumor-A case and review of the literature

Transitional meningioma (TM) is an uncommon benign meningioma. Transitional meningioma is a WHO grade I meningioma characterized by the coexistence of meningothelial cells and fibrous architectural patterns. A35 year female presented with history of intermittent fever, headache of 1 month duration. And since last 2 days with altered level of consciousness and vomiting.: MRI of the brain was performed using TI weighted spin echoI2 weighted turbo spin echo and turbo Fluid-attenuated inversion recovery: FLAIR diffusion sequences. It showed a large, lobulated, enhancing lesion in right fronto-temporal region, along right greater wing of sphenoid suggestive of meningioma. Surgical excision of tumor was done. On histopathology showed a benign tumor consists of meningothelial and fibrous proliferation. The meningothelial cells were arranged in fascicles, with the fibroblastic tumor in syncytial pattern. The nuclei were round, uniform without nucleoli. The chromatin was fine and open. The tumor cells were spindle having abundant pink cytoplasm, indistinguishable cell membranes and bland nuclear features. Mitotic figures and atypia were absent .Scattered Psammoma bodies were noted. Histopathological diagnosis was gives as benign WHO grade 1 tumor- transitional meningioma.Due to enhanced and improved imaging, histopathological techniques the increased incidence of meningiomas is observed and it will be helpful for better outcomes of patients. We are presenting this case of transitional meningioma benign tumor WHO grade1for its clinical, radioimaging and histopatholgical findings.

Does Housing Status Matter in Emergency Medical Services Administration of Naloxone? A Prehospital Cross-sectional Study.

Introduction: Persons experiencing homelessness (PEH) use emergency medical services (EMS) at disproportionately high rates relative to housed individuals due to several factors including disparate access to healthcare. Limited access to care is compounded by higher rates of substance use in PEH. Despite growing attention to the opioid epidemic and housing crisis, differences in EMS naloxone administration by housing status has not been systematically examined. Our objective in this study was to describe EMS administration of naloxone by housing status in the City of Los Angeles. Methods: This was a 12-month retrospective, cross-sectional analysis of electronic patient care reports (ePCRs) for all 9-1-1 EMS incidents attended by the Los Angeles Fire Department (LAFD), the sole EMS agency for the City of Los Angeles during the study period, January-December 2018. During this time, the City had a population of 3,949,776 with an estimated 31,825 (0.8%) PEH. We included in the study individuals to whom LAFD responders had administered naloxone. Housing status is a mandatory field on ePCRs. The primary study outcome was the incidence of EMS naloxone administration by housing status. We used descriptive statistics and logistic regression models to examine patterns by key covariates. Results: There were 345,190 EMS incidents during the study period. Naloxone was administered during 2,428 incidents. Of those incidents 608 (25%) involved PEH, and 1,820 (75%) involved housed individuals. Naloxone administration occurred at a rate of 19 per 1,000 PEH, roughly 44 times the rate of housed individuals. A logistic regression model showed that PEH remained 2.38 times more likely to receive naloxone than their housed counterparts, after adjusting for gender, age, and respiratory depression (odds ratio 2.38, 95% confidence interval 2.15-2.64). The most common impressions recorded by the EMS responders who administered naloxone were the same for both groups: overdose; altered level of consciousness; and cardiac arrest. Persons experiencing homelessness who received naloxone were more likely to be male (82% vs 67%) and younger (41.4 vs 46.2years) than housed individuals. Conclusion: In the City of Los Angeles, PEH are more likely to receive EMS-administered naloxone than their housed peers even after adjusting for other factors. Future research is needed to understand outcomes and improve care pathways for patients confronting homelessness and opioid use.

Comparing the Effect of Foot Reflexology Massage and Familiar Sensory Stimulation on the Level of Consciousness of Trauma Patients Admitted to Intensive Care Units: A Clinical Trial Study

Background: Traumatic brain injury (TBI) is an acquired brain tissue injury with different severities that leads to a change in the patient’s level of consciousness. Objectives: The present study aimed to compare the impact of foot reflexology massage and familiar sensory stimulation on the level of consciousness of trauma patients admitted to the intensive care units (ICUs) of Khatam Al-Anbia Hospital in Zahedan in 2021. Methods: This quasi-experimental study was conducted with a pretest-posttest design on 135 trauma patients with an altered level of consciousness admitted to the ICUs of Khatam Al-Anbia Hospital in Zahedan in 2021. The participants were selected using convenience sampling from the patients who met the inclusion criteria and were randomly assigned to 3 groups: Foot reflexology massage, familiar sensory stimulation, and control groups (each with 45 patients). The foot reflexology massage group received reflex massage on both feet for 30 minutes, the familiar sensory stimulation group received familiar sensory stimulation for 45 minutes, and the control group received ICU routine care. The interventions were carried out for 1 week in 2 morning and evening shifts. The patient’s consciousness level was measured and recorded using the Glasgow Coma Scale (GCS) 5 minutes before and 30 minutes after the intervention. The data were analyzed using SPSS version 22, as well as using analysis of variance (ANOVA), paired samples t-test, independent samples t-test, and analysis of covariance (ANCOVA) at a significance level of 0.05 (P < 0.05). Results: The data showed that the average consciousness score for the patients in both foot reflexology massage and familiar sensory stimulation groups increased significantly after the intervention compared to the control group (P = 0.001), but the 2 interventions were not significantly different in improving the level of consciousness of the patients. Conclusions: Foot reflexology massage and familiar sensory stimulation were both equally effective in increasing the level of consciousness of trauma patients with an altered level of consciousness, and none of them was superior to the other. Thus, nurses can use these 2 complementary medicine methods to speed up the improvement of consciousness of patients with TBI.

Assessing Patients With Altered Level of Consciousness.

Patients with alterations in level of consciousness are among the most difficult to assess, so knowledge of how to assess these patients is important for tracking trends and identifying changes. This article discusses methods used to assess patients admitted with an altered level of consciousness and describes the neurological assessment of and potential causes for altered level of consciousness. Identifying and understanding certain examination findings enable faster recognition and intervention for life-threatening neurological events, directly impacting outcomes for neurologically compromised individuals.

Intraventricular Neurocysticercosis: Comparative Analysis of Different Localizations. Clinical Course and Treatment. A Systematic Review.

Background Neurocysticercosis is significant due to its high prevalence and considerable morbidity and mortality. The intraventricular form of NCC is less common than parenchymal, may have a rapidly progressive course and it requires a corresponding therapeutic response. Despite the extensive literature dealing with NCC and intraventricular cystic lesions, no systematic reviews have addressed similar work related to the clinical course and treatment of the infestation. Our main objective was to analyze the clinical type of the disease and the management for each ventricle separately on the basis of case reports or series of patients with individual data on the course of the disease and its treatment. As a control group, we used data on signs&symptoms and treatment of patients from published series on intraventricular neurocysticercosis. Method We performed a search in the Medline database. Google Scholar was also randomly searched. We extracted the following data from the eligible case/series: age and gender, symptoms, clinical signs, diagnostic examinations and findings, localization, treatment, follow-up period, outcome, and publication year. All data are presented in the form of absolute and relative numbers. The frequency of signs and symptoms, treatment and outcomes of the observed groups were checked by the Chi-square test and Fisher's test. The hypothesis was tested with p <0.05 as statistical significance. Results We selected 160 cases of intraventricular neurocysticercosis (IVNCC) and divided them according to their localization into five categories. Hydrocephalus was recognized in 134 cases (83.4%). Patients with isolated IVNCCare are younger (P=.0264) and have a higher percentage of vesicular cysts (p <.00001). In mixed IVNCC, degenerative and multiple confluent cysts predominate (p = 0.00068). Individuals carrying fourth + third ventricular cysts (potentially obstructive form) are younger than individuals with lateral ventricles (potentially less obstructive forme) (p = .0083). The majority of patients had individual symptoms for a longer period before the acute onset of the disease (p <.00001). The predominant clinical manifestation is headache (88.7%); the proportion within the groups ranged from 100% to 75% without statistical significance (p.074214). The same was true for patients with symptoms of vomiting or nausea, who had a lower and roughly balanced percentage of 67.7% to 44.4% (p.34702). Altered level of consciousness (ranging from 21% to 60%) and focal neurological deficit (from 51.2% to 15%) are the only clinical category with statistical significance (p <0.001 and p.023948 ). Other signs and symptoms were less frequent and statistically irrelevant. Surgical resection of the parasite was the predominant type of treatment, varying from 55.5% to 87.5% (p- .02395); endoscopy (48.2%) and craniotomy (24.4%), each individually, showed statistical significance (.00001 and .000073, respectively). The difference was also relevant among patients who had CSF diversion performance with/without medical treatment (p-.002312. Postoperatively, 31.8% of patients received anthelmintics with/without anti-inflammatory or other drugs. Endoscopy, open surgery, and postoperative antiparasitic therapy showed statistical differences (p < 0.001). Favorable outcomes or regression of symptoms were recorded in 83.7%, mortality 7.5%. In the case series, the clinical signs&symptoms were as follows: headache-64%, nausea and vomiting 48.4%, focal neurological deficit 33.6% and altered level of consciousness 25%. Open surgery was the predominant form of intervention (craniotomy (57.6% or endoscopy 31.8%); with statistical significance between them (p< .00001). Conclusion. Ventricular neurocysticercosis is an alarming clinical condition. Hydrocephalus is the dominant diagnostic sign. Isolated IVNCC patients were recognized at a younger age than Mix.IVNCC individuals; poeple with cysts in the fourth and third ventricles (as a potentially more occlusive type of disease), presented their symptoms at a younger age than individuals with LVNCC. The majority of patients had long-term signs and symptoms before the acute onset of the disease. Headache, nausea& vomiting are the most common symptoms of infestation accompanied by altered sensorium and focal neurological deficits. Surgery is the best treatment option. A sudden increase in ICP due to cerebrospinal fluid obstruction with a successive cerebral hernia is the leading cause of fatal outcomes.

The etiology and mortality of altered level of consciousness in the emergency room: before and after coronavirus disease

Background: Coronavirus disease 2019 (COVID-19) has resulted in social, economic, medical, and psychological changes. New-onset altered level of consciousness (ALC) is a classical presentation in real-world medicine. This study investigated changes in ALC in the emergency room (ER) in the periods before (BC) and after (AC) COVID-19.Methods: This was a retrospective study of patients with ALCs who visited the ER of a tertiary referral center, and their medical records BC and AC were compared. A consortium allocated and analyzed the etiologies of ALC in a case-by-case discussion. The time point for etiological assessment was the time of discharge from the ER.Results: In total, 1,936 patients with ALCs (731 and 1,205 in BC and AC, respectively) were investigated. The most common etiology was systemic infection (25.9%), followed by metabolic causes (20.8%). Systemic infections (22.9% vs. 30.8%, P&lt;0.001) and stroke (14.6% vs. 18.2%, P=0.037) were lower in AC than in BC, respectively, whereas rates of toxicity (15.4% vs. 6.0%, P&lt;0.001) and traumatic brain injury (TBI; 5.9% vs. 0.8%, P&lt;0.001) were higher in AC than in BC. The overall mortality rate of ALC in the ER was 18.5%.Conclusion: This study demonstrated that the major etiologies of ALC in the ER were extra-cranial (58.5%). The mortality of ALC in the ER and the incidence of toxic cause and TBI increased in AC, suggesting a change in medical circumstances after the Pandemic.

Encefalopatía inducida por contraste en pacientes con enfermedad renal crónica avanzada: aquello que el nefrólogo necesita saber

Contrast-induced encephalopathy is a neurological complication related to contrast used in endovascular procedures or computed tomography (CT). The main risk factors are arterial hypertension, diabetes mellitus, chronic kidney disease (CKD), hyperosmolar contrasts, the amount of infused contrast and its direct infusion in the posterior cerebral territory, or pathologies with blood–brain barrier damage. Symptomatology is non-specific and may present as altered level of consciousness, neurological focality or seizures. Diagnosis is done by exclusion after ischemic or hemorrhagic stroke has been ruled out; CT or MRI are useful for differentiation. Generally, it appears shortly after exposure and the symptoms lasts 48–72 h with complete recovery, although cases with persistence of symptoms or longer duration have been described. Treatment consists of monitoring, supportive measures and renal replacement therapy (RRT) with hemodialysis (HD) in patients in chronic RRT program. It is important for the nephrologist to be aware of this entity given the susceptibility of the patient on HD as well as its potential therapeutic role in these patients.

Abstract #1377584: Brain on Fire: A Case of Hashimoto's Encephalitis in a 29-Year-Old Female

A 29-year-old female presents to the hospital for insomnia, hallucination, and bizarre behavior. The patient had been feeling well until approximately three days early when she became psychotic after fasting from food for three days. She began having auditory and visual hallucinations and then started having seizures. Initially, the patient was admitted to a hospital in another city where she was diagnosed with Autoimmune Encephalitis for which she received IVIg. Brain MRI showed questionable T2 changes around the fourth ventricle on the left during hospital admission. The patient was discharged home after her symptoms improved. However, she was brought to our hospital for psychiatric consultation as her condition deteriorated. Upon arrival at Larkin Community Hospital, the patient was hemodynamically stable, breathing room air, and continued to complain of having delusions and hallucinations. Initial Vital Signs: BP: 122/74 mmHg, HR: 70 bpm, RR: 18, T: 98°F. weight 56.2 kg, BMI 24.21. She was in nonacute distress, although anxious with pressured speech. She was cooperative and able to follow commands and track the examiner. Her NIH Stroke Scale/Score (NIHSS) was 0 and Glasgow Coma Scale (GCS) was 15. She denied using illicit drugs, smoking, and alcohol. Neurology decided to repeat LP CSF r/o NMDA Antibody encephalitis and started empirically a 5-day course of azithromycin to cover for streptococcal infections while awaiting further results. Thyroglobulin antibodies were ordered to rule out Steroids Responsive Encephalopathy and it came back elevated (91.2). She was started on Solu-Medrol 500mg IV daily for 3 days which was increased to 1000mg IV daily to complete 5 days. Even though, she developed tachycardia in the 120s; she started feeling much better as well as improved her symptoms. “Steroid-responsive encephalopathy associated with autoimmune thyroiditis” (SREAT) is an uncommon condition that is associated with Hashimoto thyroiditis. It is also called Hashimoto encephalopathy (HE). This condition was originally described in 1966 by Brain et al1. HE is a rare disorder with an approximate prevalence of 2/100,0002. It affects women more often than men. This diagnosis is typically made when a patient has encephalopathy associated with antithyroid (anti-thyroid peroxidase [TPO]) and/or anti-thyroglobulin (TG) antibodies, when other causes have been excluded. The symptoms typically seen include subacute onset of confusion with altered level of consciousness, seizures, and myoclonus. Based on the literature review of 251 cases of SREAT by Laurent et al3, SREAT has various presentations including coma to isolated psychiatric disorder. This disorder is thought to be immune mediated as opposed to being the result of an altered thyroid state on the nervous system. In most of the reported cases of SREAT, the patients are euthyroid during the presentation of symptoms. However, the exact mechanism of SREAT is still unknown. The diagnosis is made after excluding other toxic, infectious, and metabolic causes of encephalopathy with examination of cerebrospinal fluid and neuroimaging.

Meningoencephalitis Secondary To Cerebrospinal Fluid Leakage From Nasopharyngeal COVID-19 Swab (P6-10.006)

<h3>Objective:</h3> NA <h3>Background:</h3> The WHO regarded the novel coronavirus as an outbreak on January 2020. The preferable initial testing to detect SARS-CoV-2 RNA was from the upper respiratory tract using nucleic acid amplification testing (NAAT) through nasopharyngeal, oropharyngeal, nasal mid-turbinate, or anterior nasal specimen. Although specimen collection is considered safe and adverse events are rare, some reported cases of cerebrospinal fluid leakage were attributed to pharyngeal swab procedures. Therefore, increased awareness of nasal and pharyngeal swab complications is necessary. <h3>Design/Methods:</h3> A 36 years old female known to have chronic idiopathic intracranial hypertension brought to the emergency department with a history of fever, altered level of consciousness, and generalized tonic-clonic seizure. She had unilateral rhinorrhea for three months following a nasopharyngeal COVID-19 swab as part of an in-vitro fertilization workup. Upon assessment in the ED, she was stuporous due to sedation effect. There was no clear rhinorrhea, no papilledema on the fundus exam, and the remaining cranial nerves examination was unremarkable. She had positive meningeal signs. A cloudy cerebrospinal fluid analysis revealed findings of bacterial meningitis with high WBC and protein. She was started on empirical antimeningeal coverage. MRI brain showed a small CSF containing space at the left inferior frontal in the olfactory groove, which is continuous with the adjacent sulci concerning for the CSF leak site. Beta-transferrin was requested by the otolaryngology team and came back positive. After fourteen days of antibiotics, she regained her baseline cognitive and functional status then was discharged in stable condition with close follow-up with neurology, otolaryngology, and MRI cisternography. <h3>Results:</h3> NA <h3>Conclusions:</h3> Our case emphasizes that awareness of potential adverse events related to nasopharyngeal swabs that became part of daily clinical practice and hospital policies must be improved. It also supports existing scattered evidence that an existing idiopathic intracranial hypertension can be associated with cerebrospinal fluid leakage. <b>Disclosure:</b> Dr. Alnafisah has nothing to disclose. Dr. Altowairqi has nothing to disclose.

Eye Movement and Coma Recovery after Cardiac Arrest (P1-7.006)

<h3>Objective:</h3> To characterize eye movements in comatose patients after cardiac arrest (CA). <h3>Background:</h3> Most patients resuscitated from CA present with altered levels of consciousness due to brain injury. One potential marker of arousal recovery is evidence of eye movements. Brainstem pathways and thalamocortical projections responsible for eye movements share similar anatomic structures responsible for arousal. Our aim is to quantify eye movements using electro-oculography (EOG) data from patients presenting with CA. <h3>Design/Methods:</h3> We are conducting a retrospective study of patients presenting within 24 hours of CA. We identify eye movements on EOG over a period of up to 72 hours, excluding periods of clinical care, sedation, and epileptiform activity. We will study the association of eye movement frequency and the following outcomes by two weeks: 1. Present corneal or pupillary reflex; 2. Eye opening (to stimuli or spontaneously); 3. Command following. Patients are excluded if they have ophthalmoplegia, dementia, or traumatic brain injury. We will compare eye movement frequency in our comatose cohort to a separate cohort of non-comatose patients who underwent sleep studies. <h3>Results:</h3> Our preliminary data consists of 100 patients, mean (± SD) age of 60.2 (± 15.3) years and 38% were female. By 2 weeks, 85% had a pupillary reflex, 75% had a corneal reflex, 43% opened eyes to stimuli, and 21% followed commands. Of 151.5 hours of EOG time across four patients, we preliminarily found eye movements present in 0.56% of total time, with a median of 0.73% and range of 0% to 2.29%. This is comparable to our cohort of 47 patients who underwent sleep studies, with eye movements present in 3.2% of N2, 2.9% of N3, and 19.8% of REM. <h3>Conclusions:</h3> Eye movements in comatose patients may be indicative of recovery potential. Understanding these differences could have prognostic significance and help in triaging care and family discussions. <b>Disclosure:</b> The institution of Mr. Cronin has received research support from American Heart Association. Miss Hwang has nothing to disclose. The institution of an immediate family member of Miss Wack has received research support from Canon Medical Systems USA, Inc. Brian Pugsley has nothing to disclose. Mary Russo has nothing to disclose. Dr. Greer has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Thieme, Inc. Dr. Greer has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for multiple. The institution of Dr. Greer has received research support from Becton Dickenson, Inc. Dr. Greer has received publishing royalties from a publication relating to health care. Dr. Ong has nothing to disclose.

A fall in isolation: reflection on a complex case

This case review focuses on a male patient who had fallen and was found to be profoundly hypothermic, with an altered level of consciousness and evidence of seizure activity. With multiple time-critical features, this clinical presentation was made particularly challenging by the presence of several human factors. A reflective model that considered these human factors in the context of the COVID-19 pandemic, when this incident occurred, was employed. Reflecting on this incident revealed how some subconscious (intuitive) thinking led to a degree of unconscious bias compounded by availability heuristics and human factors present. This meant that the author encountered difficulty when trying to obtain peripheral vascular access and, although several alternative interventions were identified, the majority of these were unavailable at the time and some would require a change to standard clinical practice for many paramedics. The only intervention that could have been used earlier in the management of this patient was rectal diazepam, but the need for this was removed by the patient's seizure activity self-terminating. Given the increasing prevalence of falls, social isolation, mental health problems, alcohol and substance misuse, especially in the pandemic, this type of case was unlikely to be an isolated event, strengthening the argument that the range of clinical interventions available to paramedics should be increased.

The case of B.M.: delirium across different settings of care

Delirium is a serious acute neuropsychiatric syndrome, characterized by acute and fluctuating inattention, other cognitive deficits, and alterations in level of consciousness, that is independently associated with several adverse outcomes. Delirium is a transdisciplinary condition since it can affect vulnerable people in all settings of care. This clinical case is the basis for a special issue on this topic in which the negative consequence of delirium and the methods to manage people affected by this condition are described across various settings of care.

Microwave Radiothermometry in Evaluating Brain Temperature Changes (Review)

Aim. This review aims to inform physicians of different specialties (anesthesiologists, intensivists, neurologists, neurosurgeons, oncologists) about the diagnostic capabilities of microwave radiothermometry, which enables to identify and analyze features of alterations of cerebral temperature in brain damage.The review displays a critical analysis of 80 recent Russian and foreign open access publications found by keywords.The review presents major clinical features and pathophysiological mechanisms of cerebral thermal balance disruptions in brain lesions. Slow responsiveness and vulnerability of cerebral thermal homeostasis regulation mechanisms that underlie development of different temperature heterogeneity levels in the cerebral cortex in healthy brain and brain lesions are highlighted. The authors postulate their concept about the critical role of hyperthermia in the pathogenesis of brain damage and disruption of interconnections in the global central regulation system. A body of evidence explaining direct association between the depth of consciousness impairment and degree of cerebral cortex temperature heterogeneity manifestation is presented. It is emphasized that a significant increase in temperature heterogeneity with areas of focal hyperthermia accompanies an acute period of ischemic stroke, while in post-comatose state usually associated with prolonged impairment of consciousness, the temperature heterogeneity significantly subsides. It has been suggested that lowering of an increased and rising of the reduced temperature heterogeneity, for example by using temperature exposure, can improve altered level of consciousness in patients with brain damage. The diagnostic capabilities of various technologies used for cerebral temperature measurement, including microwave radiothermometry (MWR), are evaluated. Data on high accuracy of MWR in measurement of the cerebral cortex temperature in comparison with invasive methods are presented.Conclusion. In healthy individuals MWR revealed a distinct daily rhythmic changes of the cerebral cortex temperature, and badly violated circadian rhythms in patients with brain lesions. Since MWR is an easy-toperform, non-invasive and objective diagnostic tool, it is feasible to use this technology to detect latent cerebral hyperthermia and assess the level of temperature heterogeneity disruption, as well as to study the circadian rhythm of temperature changes.

Approach to acute psychosis in older adults.

Approach to acute psychosis in older adults.