Presence Of Focal Neurological Deficits Research Articles

Development of clinical prediction model to guide the use of CT head scans for non-traumatic Thai patient with seizure: A cross-sectional study.

The aim of this study was to develop clinical predictor tools for guiding the use of computed tomography (CT) head scans in non-traumatic Thai patients presented with seizure. A prediction model using a retrospective cross-sectional design was conducted. We recruited adult patients (aged ≥ 18 years) who had been diagnosed with seizures by their physicians and had undergone CT head scans for further investigation. Positive CT head defined as the presence of any new lesion that related to the patient's presented seizure officially reported by radiologist. A total of 9 candidate predictors were preselected. The prediction model was developed using a full multivariable logistic regression with backward stepwise elimination. We evaluated the model's predictive performance in terms of its discriminative ability and calibration via AuROC and calibration plot. The application was then constructed based on final model. A total of 362 patients were included into the analysis which comprising of 71 patients with positive CT head findings and 291 patients with normal results. Six final predictors were identified including: Glasgow coma scale, the presence of focal neurological deficit, history of malignancy, history of CVA, Epilepsy, and the presence of alcohol withdrawal symptom. In terms of discriminative ability, the final model demonstrated excellent performance (AuROC of 0.82 (95% CI: 0.76-0.87)). The calibration plot illustrated a good agreement between observed and predicted risks. This prediction model offers a reliable tool for effectively reduce unnecessary use and instill confidence in supporting physicians in determining the need for CT head scans in non-traumatic patients with seizures.

Prognosis and Outcome of Cerebral Sinus Venous Thrombosis—A Multicenter Cohort Study

Objectives. Cerebral sinus venous thrombosis (CSVT) is a rare stroke subtype and data regarding prognostic factors to predict outcomes are lacking. Thus, we aimed to identify predictors for outcome among CSVT patients. Materials and Methods. Prospective CSVT databases from four academic medical centers were retrospectively studied. Demographics, clinical presentations, risk factors, radiological, and outcome parameters were compared. Results. Out of 508 patients diagnosed with CSVT, 21 patients (4%) died, and 91 (18.6%) had unfavorable outcome ( mRS ≥ 2 ). Age (55.0 vs. 38.5, p < 0.001 ), hypertension (26% vs. 6%, p < 0.001 ), hyperlipidemia (23% vs. 6%, p < 0.001 ), diabetes (17% vs. 4%, p < 0.001 ), malignancy (35% vs. 11%, p < 0.001 ), absence of headache (51% vs. 78%, p < 0.001 ), focal neurological deficit (54% vs. 19%, p < 0.001 ), and ICH (28% vs. 13%, p < 0.001 ) were all associated with unfavorable outcome. After multivariate analysis malignancy (OR 4.2, p = 0.003 ), the presence of focal neurological deficit (OR 5.2, p < 0.001 ) and the presence of headache upon presentation (OR 0.334, p = 0.018 ) remained significant predictors for favorable outcome. Conclusions. Among CSVT patients, malignancy, focal neurological deficits, and absence of headache at presentation were associated with unfavorable outcomes.

Diagnostic yield of CT head in delirium and altered mental status-A systematic review and meta-analysis.

CT head is commonly performed in the setting of delirium and altered mental status (AMS), with variable yield. We aimed to evaluate the yield of CT head in hospitalized patients with delirium and/or AMS across a variety of clinical settings and identify factors associated with abnormal imaging. We included studies in adult hospitalized patients, admitted to the emergency department (ED) and inpatient medical unit (grouped together) or the intensive care unit (ICU). Patients had a diagnosis of delirium/AMS and underwent a CT head that was classified as abnormal or not. We searched Medline, Embase and other databases (informed by PRISMA guidelines) from inception until November 11, 2021. Studies that were exclusively performed in patients with trauma or a fall were excluded. A meta-analysis of proportions was performed; the pooled proportion of abnormal CTs was estimated using a random effects model. Heterogeneity was determined via the I2 statistic. Factors associated with an abnormal CT head were summarized qualitatively. Forty-six studies were included for analysis. The overall yield of CT head in the inpatient/ED was 13% (95% CI: 10.2%-15.9%) and in ICU was 17.4% (95% CI: 10%-26.3%), with considerable heterogeneity (I2 96% and 98% respectively). Heterogeneity was partly explained after accounting for study region, publication year, and representativeness of the target population. Yield of CT head diminished after year 2000 (19.8% vs. 11.1%) and varied widely depending on geographical region (8.4%-25.9%). The presence of focal neurological deficits was a consistent factor that increased yield. Use of CT head to diagnose the etiology of delirium and AMS varied widely and yield has declined. Guidelines and clinical decision support tools could increase the appropriate use of CT head in the diagnostic etiology of delirium/AMS.

Factors Associated With New-Onset Seizures Following Stereotactic Radiosurgery for Newly Diagnosed Brain Metastases

PurposeStereotactic radiosurgery (SRS) is a highly effective therapy for newly diagnosed brain metastases. Prophylactic antiepileptic drugs are no longer routinely used in current SRS practice, owing to a perceived low overall frequency of new-onset seizures and potential side effects of medications. It is nonetheless desirable to prevent unwanted side effects following SRS. Risk factors for new-onset seizures after SRS have not been well established. As such, we aimed to characterize variables associated with increased seizure risk. Methods and MaterialsPatients treated with SRS for newly diagnosed brain metastases between 2013 and 2016 were retrospectively reviewed at a single institution. Data on baseline demographics, radiation parameters, and clinical courses were collected. ResultsThe cohort consisted of 305 patients treated with SRS without prior seizure history. Median age and baseline Karnofsky Performance Scale score were 64 years (interquartile range, 55-70) and 80 (interquartile range, 80-90), respectively. Twenty-six (8.5%) patients developed new-onset seizures within 3 months of SRS. There was no association between new-onset seizures and median baseline Karnofsky Performance Scale score, prior resection, or prior whole brain radiation therapy. There were significant differences in the combined total irradiated volume (12.5 vs 3.7 cm3, P < .001), maximum single lesion volume (8.8 vs 2.8 cm3, P = .003), lesion diameter (3.2 vs 2.0 cm, P = .003), and number of lesions treated (3 vs 1, P = .018) between patients with and without new-onset seizures, respectively. On multivariate logistic regression, total irradiated volume (odds ratio, 1.09 for every 1-cm1 increase in total volume; confidence interval, 1.02-1.17; P = .016) and pre-SRS neurologic symptoms (odds ratio, 3.08; 95% confidence interval, 1.19-7.99; P = .020) were both significantly correlated with odds of seizures following SRS. ConclusionsOur data suggest that larger total treatment volume and the presence of focal neurologic deficits at presentation are associated with new-onset seizures within 3 months of SRS. High-risk patients undergoing SRS may benefit from counseling or prophylactic antiseizure therapy.

A Prospective Comparative Evaluation of Surgery and Conservative Treatment for Compound Depressed Skull Fractures

The Brain Trauma Foundation issued level III evidence guidelines for surgical management of compound depressed fractures. However, some patients undergo successful conservative treatment. This study compares these 2 treatment modalities. This prospective study included 67 patients with compound depressed skull fractures with surgical indications and a minimum follow-up of 6 months. Depressed fractures in front of the hairline (operated on for cosmetic reasons) and associated with significant intracranial injuries were excluded. Those who gave consent for surgery were included in the surgical group, and those who denied were included in the conservative group. The surgical group had 38 patients and the conservative group had 29. Both groups were comparable in mean age, gender, Glasgow Coma Scale score, head injury severity, depth of fractures, and follow-up duration. Focal neurologic deficits were observed in 19 patients at presentation and were higher in the surgical group. Mean hospital stay was significantly shorter in the conservative group. Mean Glasgow Outcome Scale score at follow-up was statistically similar in both groups (P= 0.13). Focal neurologic deficits improved equally in both groups (P= 0.67). The severity of traumatic brain injury (P= 0.004) and the presence of focal neurologic deficits (P < 0.001) affected the neurologic outcomes. The age, gender, mode of treatment (surgery vs. conservative), surgical site infections, and seizures did not affect neurologic outcomes. The overall complication rates were similar among groups (P= 0.50). New-onset focal neurologic deficits, seizures, and infection rates were not significantly different among the groups (P= 0.98, P= 0.72, P= 0.69). Conservative management has equivalent neurologic outcomes and complications compared with surgical management.

An Uncommon Presentation of Cryptococcal Meningoencephalitis

Cryptococcal meningoencephalitis (CM) remains a common cause of central nervous system infections. Patients usually present with headache, fever, malaise, and altered mental status over several weeks. Signs are often absent, but they may include meningism, papilledema, cranial nerve palsies, and depressed level of consciousness. Individuals with CM can occasionally present with small vessel vasculitis causing cerebral lesions. The literature regarding patterns of cerebrovascular injury in CM is scarce.We describe a case of CM in which an unusual presentation was observed: transient focal neurological symptoms initially with absence of fever that led to a misleading primary diagnosis of transient ischemic attack. Since neurological symptoms may be a manifestation of a cryptococcal infection, it is necessary to have a high degree of suspicion for this pathology in the presence of focal neurological deficits, even in patients with vascular risk factors, requiring a thorough etiological investigation.

Abstract P460: Comparison of Hemorrhagic Posterior Reversible Encephalopathy Syndrome and Hemorrhagic Reversible Cerebral Vasoconstriction Syndrome

Introduction: Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) are diagnoses that have a clinical and radiographic overlap. One particular overlap includes the presence of hemorrhage, which we studied in each population to determine its effect on outcomes. Objective: To compare characteristics and outcomes of hemorrhagic PRES and hemorrhagic RCVS populations. Methods: We conducted a review of the electronic health record at a single tertiary center from January 2008 to December 2018. Inclusion criteria were 18 years or older with clinical and radiographic evidence of PRES or RCVS. Patient demographics, presenting symptoms, imaging findings, and outcomes were compared between PRES and RCVS groups. Poor outcome was defined as discharge to skilled nursing facility or death. Analysis was performed using Pearson’s Chi-Square test. Results: Among 281 PRES and 98 RCVS cases, intracranial hemorrhage was seen on imaging in 51 PRES cases (18%) and 34 RCVS cases (35%). Headache was present in all patients with hemorrhagic RCVS but only seen in 40% of hemorrhagic PRES. Use of antidepressants or drugs of abuse was more frequent with hemorrhagic RCVS (53%) as compared to hemorrhagic PRES (7%, p &lt;0.05). Among hemorrhagic PRES, presence of intraparenchymal hemorrhage but not subarachnoid hemorrhage was associated with vasoconstriction on arterial imaging (p&lt;0.05). Length of stay was longer for both hemorrhagic PRES and hemorrhagic RCVS (p&lt;0.001) compared those without hemorrhage. Presence of focal neurological deficits, motor and sensory, was associated with poor outcomes in hemorrhagic RCVS patients (p&lt;0.05). Discharge to a rehabilitation facility was associated with hemorrhagic PRES (p&lt;0.05), no association in those without hemorrhage. There is no evidence that discharge location is significantly different between RCVS hemorrhage and non-hemorrhage groups. Conclusion: Hemorrhage in PRES and RCVS is associated with more clinical deficits at presentation and longer hospital stays. Underlying vasoconstriction is frequent and associated with hemorrhagic PRES.

57-Year-Old Woman With Weakness and Word-Finding Difficulties

57-Year-Old Woman With Weakness and Word-Finding Difficulties

Factors influencing therapy choice and clinical outcome in cerebral venous sinus thrombosis

We aimed was to assess the factors influencing therapy choice and clinical outcome after 3–4 months in patients with cerebral venous sinus thrombosis (CVST). In a retrospective, bi-centric study, the set consisted of 82 consecutive CVST patients (61 females; mean age 33.5 ± 15.7 years). Following data were collected: baseline characteristics, presence of gender-specific risk factors (GSRF), location and extent of venous sinus impairment, clinical presentation, type of treatment, recanalization, presence of parenchymal lesions, and clinical outcome after 3–4 months (assessed using the modified Rankin Scale [mRS], with excellent outcome defined as mRS 0–1). Multivariate logistic regression analysis was used for statistical evaluation. After 3–4 months, complete recovery was achieved in 41 (50%) and excellent clinical outcome in 67 (81.7%) patients. Female sex (OR 0.11; p = 0.0189) and presence of focal neurologic deficit (OR 0.16; p = 0.0165) were identified as significant independent negative predictors and, the presence of GSRF (OR 15.63; p = 0.0011) as significant independent positive predictor of excellent clinical outcome. In conclusion, in our CVST patients, the presence of GSRF was associated with excellent clinical outcome, while the female sex itself was associated with poorer clinical outcome.

S1137 Low Yield of Head Computed Tomography (HCT) in Cirrhotic Patients Presenting With Altered Mentation

INTRODUCTION: Hepatic encephalopathy is a known complication of liver cirrhosis that often manifests as a change in mental status. This study aims to investigate the utility in obtaining a head computerized tomography (HCT) in patients presenting with hepatic encephalopathy by correlating presence or absence of focal neurological deficits (FND) to imaging findings. METHODS: Retrospective review of cirrhotic patient admissions with hepatic encephalopathy between 2016-2018 at William Beaumont Hospital in Michigan was performed. Two reviewers independently reviewed automated reports generated for variables of interest using an electronic health record query tool. Low risk indication for HCT was defined as altered mental status in the absence of trauma or FNDs. Descriptive statistics, univariate analyses by t-tests/2 tests and logistic regression were performed to identify clinical features associated with acute abnormalities on HCT using SPSS. RESULTS: 520 unique admissions were reviewed. Mean age was 63.4 ± 12.1 years, M:F ratio was 1.31:1, 187 (36.0%) had alcoholic cirrhosis, and median MELD score was 17 (13-23). Indication for HCT was altered mental status (AMS) in 408 (78.5%) patients and FNDs only reported in 24 (4.6%) patients. 13 (2.5%) patients had acute intracranial pathology (7 hemorrhagic stroke, 2 ischemic stroke, 4 subdural hematoma) on HCT. Presence of FNDs (OR: 6.9, 95% CI: 1.8–27.1), a high risk indication for HCT (OR: 6.2, 95% CI: 2.0–19.3), and antiplatelet use (OR: 5.8, 95% CI: 1.6–21.2) were positive correlates of acute intracranial pathology on HCT. Age, sex, MELD score, hemoglobin, platelet count, race, and cirrhosis etiology did not correlate with HCT abnormalities. Number needed to screen to identify one acute pathology was 14 vs. 82 for high risk indications vs. low risk indications. CONCLUSION: Routine HCTs in cirrhotic patients presenting with hepatic encephalopathy with AMS in the absence of history of trauma, FNDs, or aspirin use are costly and of low diagnostic yield. In addition, in patients with liver cirrhosis, the risks and benefits of aspirin use should be carefully weighed.Table 1.: Cohort demographics and clinical characteristicsTable 2.: Head computed tomography (HCT) findings and indications

Cerebrovascular events in COVID-19 patients.

Neurological manifestations in patients with COVID-19 are more frequently being reported. Cerebrovascular events have been reported in around 3% of patients. In this review we summarize the published literature on cerebrovascular events in patients with COVID-19 as available on the PubMed database. So far, 3 studies have reported cerebrovascular events. Cerebrovascular events were identified on screening patients with decreased consciousness or in the presence of focal neurological deficits. These events were common in elderly, critically ill patients and in patients with prior cardio-cerebrovascular comorbidities. The diagnosis of cerebrovascular events was confirmed with computed tomography of the brain in most studies reporting neurological events. Multiple pathological mechanisms have been postulated regarding the process of neurological and vascular injury among which cytokine storm is shown to correlate with mortality. Patients with severe illness are found to have a higher cardio- cerebrovascular comorbidity. With an increasing number of cases and future prospective studies, the exact mechanism by which these cerebrovascular events occur and attribute to the poor outcome will be better understood.

Epileptic seizures in cerebral venous sinus thrombosis: Subgroup analysis of VENOST study

PurposeThe aim of this study is to evaluate the presence and prognostic impact of early seizures in cerebral venous sinus thrombosis patients (CVST). MethodVENOST is a retrospective and prospective national multicenter observational study. CVST patients with or without epileptic seizures (ES) were analyzed and compared in terms of demographic and imaging data, causative factors, clinical variables, and prognosis in a total of 1126 patients. ResultsThe mean age of the patients in the ES group was 39.73 ± 12.64 and 40.17 ± 14.02 years in the non-ES group (p > 0.05). Epileptic seizures were more common (76.6 %) in females (p < 0.001). Early ES occurred in 269 of 1126 patients (23.9 %). Epileptic seizures mainly presented in the acute phase (71.4 %) of the disease (p < 0.001). Majority of these (60.5 %) were in the first 24 h of the CVST. The most common neurological signs were focal neurologic deficits (29.9 %) and altered consciousness (31.4 %) in the ES group. Superior sagittal sinus (SSS) and cortical veins (CV) involvement were the most common sites of thrombosis and the mostly related etiology were found puerperium in seizure group (30.3 % vs 13.9 %). Patients with seizures had worse outcome in the first month of the disease (p < 0.001) but these did not have any influence thereafter. ConclusionsIn this largest CVST cohort (VENOST) reported female sex, presence of focal neurological deficits and altered consciousness, thrombosis of the SSS and CVs, hemorrhagic infarction were risk factors for ES occurrence in patients with CVST.

Identification of predictors of cerebrovascular infarcts in patients with tuberculous meningitis.

Tuberculous meningitis (TBM) remains common in developing countries. Cerebrovascular infarct (CI) in TBM occurs in 15%-57% of patients. Literature regarding the predictors of central nervous system (CNS) infarct in patients with TBM is scanty, and the outcome of these events is unknown. The aim of this study is to evaluate the predictors of CI among patients with TBM at a tertiary care center in South India and to compare the impact of CI on the prognosis and outcomes in terms of mortality and morbidity. All patients who were confirmed to have TBM and CNS infarcts/stroke were included in this study retrospectively. Forty-six patients had appropriate imaging, and they were enrolled in the study as cases. Patients without infarct were matched with age and sex as controls. Details of the course of the disease, the extent of CNS involvement, and treatment were compared between the two arms. The mean age of patients with and without infarct was similar. The presence of basal meningeal inflammation, hydrocephalus, focal neurological deficit, and cranial nerve palsy, was higher in patients with infarct. Independent predictors of infarcts in a patient with TBM were Medical Research Council (MRC) staging of II or more, presence of focal neurological deficit, cranial nerve palsy, and presence of hydrocephalus, meningeal enhancement on neuroimaging. Presences of infarcts were independently associated with a higher odds ratio of 2.58 for poor outcome, 4.48 for a longer duration of hospital stay, and odds ratio of 8.85 for the requirement of multiple hospitalizations. CI involvement in TBM has higher morbidity, with longer stay, recurrent admission.

Predictors of subacute hematoma expansion requiring surgical evacuation after initial conservative treatment in patients with acute subdural hematoma.

The aim of this study was to clarify the factors associated with requiring subacute surgery in patients with acute subdural hematoma (ASDH) treated conservatively at admission. Among the patients with ASDH admitted to our hospital from 2007 to 2018, we retrospectively reviewed data for 200 patients initially treated conservatively. We compared patients' characteristics, medical history, radiological findings, and clinical outcomes and differences between patients undergoing subacute surgery or no surgery. Of the 200 patients treated conservatively, 17 (8.5%) patients underwent subacute surgery due to deterioration of their clinical and/or computed tomography (CT) findings, while 183 (91.5%) patients did not undergo subacute surgery. There were significant differences in the presence of focal neurological deficits, modified Rankin Scale scores, degree of midline shift, hematoma thickness, hematoma volume, cella media index, Sylvian fissure ratio, and hematoma density between the two groups. Large hematoma, brain atrophy, and hematoma density may be useful predictors for the need for subacute surgery in patients with ASDH treated conservatively at admission. Intensive investigation of clinical findings or CT images is warranted in patients with adverse prognostic factors, even if their initial symptoms are mild.

Acute Headache in the Emergency Setting.

Acute headache is a common symptom and is reported by approximately 2%-4% of patients who present to the emergency department. Many abnormalities manifest with headache as the first symptom, and it is crucial to obtain a patient's complete clinical history for correct diagnosis. Headache onset, duration, and severity; risk factors such as hypertension, immunosuppression, or malignancy; and the presence of focal neurologic deficits or systemic symptoms may aid the radiologist in deciding whether imaging is appropriate and which modality to choose. Imaging findings are more likely to be abnormal in patients with a "thunderclap" headache than in those with headaches of lesser severity. The causes of headache in the emergency setting are various. They may manifest at imaging as subarachnoid hemorrhage (ruptured aneurysm, reversible vasoconstriction syndrome, or pituitary apoplexy), parenchymal hemorrhage (hypertension, ruptured arteriovenous malformation, cerebral amyloid angiopathy, dural arteriovenous fistula, or sinus thrombosis), or parenchymal edema (posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, sinus thrombosis, or encephalitis). Alterations in intracranial pressure that are related to idiopathic intracranial hypertension or spontaneous intracranial hypotension and prior lumbar puncture or epidural injection may manifest with specific imaging findings. With accumulating knowledge of disease pathophysiology, radiologists have started to play a more central role in making the correct diagnosis. This article reviews multiple causes of acute headache and their characteristic appearances at multimodality imaging and familiarizes the reader with current concepts in imaging.Online supplemental material is available for this article.©RSNA, 2019.

Early, delayed, and expanded intracranial hemorrhage in cerebral venous thrombosis.

One of the most important prognostic factors of cerebral venous sinus thrombosis (CVST) is intracranial hemorrhage (ICH). We studied the risk factors, clinical, and radiologic characteristics of early, delayed, and expanded ICH in Iranian patients with CVST. In a retrospective study, from August 2012 to September 2016, all adult patients with a confirmed diagnosis of CVST were recruited. Demographic, clinical, and radiologic characteristics of the patients were recorded. The predictors of early, delayed, and expanded ICH were assessed through logistic regression analysis. Among 174 eligible patients, 35.1% of the patients had early ICH. Delayed and expanded hemorrhage occurred in 5% and 7.4% of the patients, respectively. Higher age was a risk factor (odds ratio [OR]=1.038, 95% confidence interval [CI]=1.008-1.069), and involvement of multiple sinuses/veins was associated with lower risk of early ICH (OR=0.432, CI=0.226-0.827). The risk of delayed ICH was higher in the patients with early hemorrhage (OR=4.44, CI: 0.990-19.94), men (OR=4.18, CI: 0.919-19.05), and those with a focal neurologic deficit on admission (OR=16.05, CI: 1.82-141.39). Acute onset was the predictor of the expansion of early ICH (OR=8.92, CI: 1.81-43.77), whereas female gender-related conditions were associated with a lower risk of hemorrhage expansion (OR=0.138, CI: 0.025-0.770). Administration of anticoagulants was associated with neither delayed (P value=.140) nor expanded hemorrhage (P-value=.623). Male gender, early hemorrhages, acute onset, and presence of focal neurologic deficit are the risk factors for delayed and/or expanded hemorrhages in the patients with CVST.

A study of risk factors and clinical outcome of stroke in children

Background: Stroke is a significant cause of neurological morbidity and mortality in children. Early recognition permits timely therapeutic intervention aimed at preventing recurrence and improving long-term outcome. The objective of this study was to determine the risk factors, clinical outcome of stroke in children and to evaluate any association between them.Methods: This was a prospective, observational study, conducted over one and a half year at a tertiary care centre. Children between 1 month to 12 years and diagnosed to have stroke were enrolled. The clinical profile, investigations and outcome of stroke were studied. Data collected was analysed using Pearson chi-square test.Results: Of 55 children enrolled, definite etiology could be determined in 44 (80%) children. The common risk factors identified were vasculitis (30.9%), vasculopathy (23.6%), hypercoagulable states (18.1%), cardiac diseases (12.7%) and bleeding diathesis (7.2%). Focal neurologic deficits (69%), convulsions (58%), altered sensorium (41.8%), fever (45.4%) and aphasia (34.5%) were the chief presenting features. The overall mortality was 30.9% and neurologic deficits were observed in 54.5%. Children with undetermined etiology had a favorable outcome compared to those with definite etiology (p=0.007). Poor outcome was witnessed with vasculitis and cardiac diseases; recurrence was common with Moyamoya disease. Presence of either of altered sensorium (p=0.0005) or convulsions (p=0.046) or visual complaints (p=0.032) or headache (p=0.042) were associated with poor outcome whereas presence of focal neurologic deficits alone predicted a better outcome (p=0.036).Conclusions: The nature of risk factor and the clinical presentation significantly influence the outcome of stroke in children.

Computerized Tomography of the Brain for Elderly Patients Presenting to the Emergency Room with Acute Confusion State in Eastern Nepal

Background: Acute confusion is a common reason for presentation of elderly patients to the emergency which may be of neurological or non-neurological origin. Computerized tomography (CT) scans are often routinely ordered to investigate the cause. &#x0D; Objective: To determine the usefulness of CT scan brain in confused elderly patients. &#x0D; Methods: A cross-sectional observational study was conducted in emergency room (ER) of B. P. Koirala Institute of Health Sciences over a period of 6 months in 84 patients above the age of 65 years who had CT scan brain done in view of acute confusion. They were reviewed for symptoms, indications of CT scan and presence of focal neurological deficits (FND). &#x0D; Results: Among patients presenting in confusion and with loss of consciousness or limb weakness, CT scan was abnormal in 90% and 92% cases respectively (p &lt;0.05) whereas those presenting with fever, cough, headache, dizziness, seizure in confusion also had abnormal CT but was statistically not significant (p&gt; 0.05). Out of 84 elderly cases of acute confusion, 52 had FND and the remaining 32 cases were without FND. Among those with FND, 40% and 46% cases had features of ischemic and hemorrhagic stroke respectively. Among the 32 without FND, 66% patients had normal scan and 38% had cerebral atrophy. In patients with Glasgow Coma Scale (GCS) &lt; 9 with FND, 75% had CT scan suggestive of hemorrhagic stroke whereas those with GCS&gt; 13 with FND, 57% and 29% cases had ischemic and hemorrhagic stroke respectively. &#x0D; Conclusion: CT scan brain for confused elderly should be advised for those with focal neurological symptoms and may be suggested in cases of head trauma or alleged history of fall irrespective of GCS and symptomatology.

Predictors of abnormal brain computed tomography findings in patients with acute altered mental status in the emergency department.

ObjectiveBrain computed tomography (CT) is commonly performed to diagnose acute altered mental status (AMS), a critically important symptom in many serious diseases. However, negative CT results are common, which result in unnecessary CT use. Therefore, this study aimed to determine the clinical factors associated with positive CT findings.MethodsPatients with acute AMS selected from an emergency department-based registry were retrospectively evaluated. Patients with non-traumatic and noncommunicable diseases on initial presentation and with Glasgow Comal Scale scores of <15 were included in the study.ResultsAmong the 367 brain CT results of patients with AMS during the study period, 146 (39.8%) were positive. In a multivariate analysis, the presence of focal neurologic deficit (odds ratio [OR], 132.6; 95% confidence interval [CI], 37.8 to 464.6), C-reactive protein level <2 mg/dL (OR, 3.9; 95% CI, 1.4 to 10.6), and Glasgow Comal Scale score <9 (OR, 2.4; 95% CI, 1.2 to 4.8) were significantly associated with positive brain CT results.ConclusionThe presence of focal neurologic deficit, initial Glasgow Comal Scale score of <9, and initial C-reactive protein levels of <2 mg/dL can facilitate the selection of brain CT to diagnose patients with acute AMS in the emergency department.

The Neurological Wake-up Test—A Role in Neurocritical Care Monitoring of Traumatic Brain Injury Patients?

The most fundamental clinical monitoring tool in traumatic brain injury (TBI) patients is the repeated clinical examination. In the severe TBI patient treated by continuous sedation in a neurocritical care (NCC) unit, sedation interruption is required to enable a clinical evaluation (named the neurological wake-up test; NWT) assessing the level of consciousness, pupillary diameter and reactivity to light, and presence of focal neurological deficits. There is a basic conflict regarding the NWT in the NCC setting; can the clinical information obtained by the NWT justify the risk of inducing a stress response in a severe TBI patient? Furthermore, in the presence of advanced multimodal monitoring and neuroimaging, is the NWT necessary to identify important clinical alterations? In studies of severe TBI patients, the NWT was consistently shown to induce a stress reaction including brief increases in intracranial pressure (ICP) and changes in cerebral perfusion pressure (CPP). However, it has not been established whether these short-lived ICP and CPP changes are detrimental to the injured brain. Daily interruption of sedation is associated with a reduced ventilator time, shorter hospital stay and reduced mortality in many studies of general intensive care unit patients, although such clinical benefits have not been firmly established in TBI. To date, there is no consensus on the use of the NWT among NCC units and systematic studies are scarce. Thus, additional studies evaluating the role of the NWT in clinical decision-making are needed. Multimodal NCC monitoring may be an adjunct in assessing in which TBI patients the NWT can be safely performed. At present, the NWT remains the golden standard for clinical monitoring and detection of neurological changes in NCC and could be considered in TBI patients with stable baseline ICP and CPP readings. The focus of the present review is an overview of the existing literature on the role of the NWT as a clinical monitoring tool for severe TBI patients.