Publications by authors named "Jan Claassen"

288 Publications

Identification of Endotypes of Hospitalized COVID-19 Patients.

Front Med (Lausanne) 2021 11;8:770343. Epub 2021 Nov 11.

Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States.

Characterization of coronavirus disease 2019 (COVID-19) endotypes may help explain variable clinical presentations and response to treatments. While risk factors for COVID-19 have been described, COVID-19 endotypes have not been elucidated. We sought to identify and describe COVID-19 endotypes of hospitalized patients. Consensus clustering (using the ensemble method) of patient age and laboratory values during admission identified endotypes. We analyzed data from 528 patients with COVID-19 who were admitted to telemetry capable beds at Columbia University Irving Medical Center and discharged between March 12 to July 15, 2020. Four unique endotypes were identified and described by laboratory values, demographics, outcomes, and treatments. Endotypes 1 and 2 were comprised of low numbers of intubated patients (1 and 6%) and exhibited low mortality (1 and 6%), whereas endotypes 3 and 4 included high numbers of intubated patients (72 and 85%) with elevated mortality (21 and 43%). Endotypes 2 and 4 had the most comorbidities. Endotype 1 patients had low levels of inflammatory markers (ferritin, IL-6, CRP, LDH), low infectious markers (WBC, procalcitonin), and low degree of coagulopathy (PTT, PT), while endotype 4 had higher levels of those markers. Four unique endotypes of hospitalized patients with COVID-19 were identified, which segregated patients based on inflammatory markers, infectious markers, evidence of end-organ dysfunction, comorbidities, and outcomes. High comorbidities did not associate with poor outcome endotypes. Further work is needed to validate these endotypes in other cohorts and to study endotype differences to treatment responses.
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http://dx.doi.org/10.3389/fmed.2021.770343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8632028PMC
November 2021

Quantitative EEG-Based Seizure Estimation in Super-Refractory Status Epilepticus.

Neurocrit Care 2021 Nov 17. Epub 2021 Nov 17.

Department of Neurology, Columbia University and NewYork Presbyterian Hospital, New York, NY, USA.

Background: The objective of this study was to evaluate the accuracy of seizure burden in patients with super-refractory status epilepticus (SRSE) by using quantitative electroencephalography (qEEG).

Methods: EEG recordings from 69 patients with SRSE (2009-2019) were reviewed and annotated for seizures by three groups of reviewers: two board-certified neurophysiologists using only raw EEG (gold standard), two neurocritical care providers with substantial experience in qEEG analysis (qEEG experts), and two inexperienced qEEG readers (qEEG novices) using only a qEEG trend panel.

Results: Raw EEG experts identified 35 (51%) patients with seizures, accounting for 2950 seizures (3,126 min). qEEG experts had a sensitivity of 93%, a specificity of 61%, a false positive rate of 6.5 per day, and good agreement (κ = 0.64) between both qEEG experts. qEEG novices had a sensitivity of 98.5%, a specificity of 13%, a false positive rate of 15 per day, and fair agreement (κ = 0.4) between both qEEG novices. Seizure burden was not different between the qEEG experts and the gold standard (3,257 vs. 3,126 min), whereas qEEG novices reported higher burden (6066 vs. 3126 min).

Conclusions: Both qEEG experts and novices had a high sensitivity but a low specificity for seizure detection in patients with SRSE. qEEG could be a useful tool for qEEG experts to estimate seizure burden in patients with SRSE.
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http://dx.doi.org/10.1007/s12028-021-01395-xDOI Listing
November 2021

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

Stroke 2021 12 29;52(12):3891-3898. Epub 2021 Sep 29.

Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.).

Background And Purpose: Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST).

Methods: Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition.

Results: Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1-4.3], <0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4], <0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229], <0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate.

Conclusions: In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.
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http://dx.doi.org/10.1161/STROKEAHA.121.035233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8608746PMC
December 2021

Dynamic Intracranial Pressure Waveform Morphology Predicts Ventriculitis.

Neurocrit Care 2021 Jul 30. Epub 2021 Jul 30.

Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8 Milstein - 300 Center, New York, NY, USA.

Background: Intracranial pressure waveform morphology reflects compliance, which can be decreased by ventriculitis. We investigated whether morphologic analysis of intracranial pressure dynamics predicts the onset of ventriculitis.

Methods: Ventriculitis was defined as culture or Gram stain positive cerebrospinal fluid, warranting treatment. We developed a pipeline to automatically isolate segments of intracranial pressure waveforms from extraventricular catheters, extract dominant pulses, and obtain morphologically similar groupings. We used a previously validated clinician-supervised active learning paradigm to identify metaclusters of triphasic, single-peak, or artifactual peaks. Metacluster distributions were concatenated with temperature and routine blood laboratory values to create feature vectors. A L2-regularized logistic regression classifier was trained to distinguish patients with ventriculitis from matched controls, and the discriminative performance using area under receiver operating characteristic curve with bootstrapping cross-validation was reported.

Results: Fifty-eight patients were included for analysis. Twenty-seven patients with ventriculitis from two centers were identified. Thirty-one patients with catheters but without ventriculitis were selected as matched controls based on age, sex, and primary diagnosis. There were 1590 h of segmented data, including 396,130 dominant pulses in patients with ventriculitis and 557,435 pulses in patients without ventriculitis. There were significant differences in metacluster distribution comparing before culture-positivity versus during culture-positivity (p < 0.001) and after culture-positivity (p < 0.001). The classifier demonstrated good discrimination with median area under receiver operating characteristic 0.70 (interquartile range 0.55-0.80). There were 1.5 true alerts (ventriculitis detected) for every false alert.

Conclusions: Intracranial pressure waveform morphology analysis can classify ventriculitis without cerebrospinal fluid sampling.
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http://dx.doi.org/10.1007/s12028-021-01303-3DOI Listing
July 2021

Research Needs for Prognostic Modeling and Trajectory Analysis in Patients with Disorders of Consciousness.

Neurocrit Care 2021 07 8;35(Suppl 1):55-67. Epub 2021 Jul 8.

Division of Neuroscience Critical Care, Departments of Anesthesiology and Critical Care Medicine and Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: The current state of the science regarding the care and prognosis of patients with disorders of consciousness is limited. Scientific advances are needed to improve the accuracy, relevance, and approach to prognostication, thereby providing the foundation to develop meaningful and effective interventions.

Methods: To address this need, an interdisciplinary expert panel was created as part of the Coma Science Working Group of the Neurocritical Care Society Curing Coma Campaign.

Results: The panel performed a gap analysis which identified seven research needs for prognostic modeling and trajectory analysis ("recovery science") in patients with disorders of consciousness: (1) to define the variables that predict outcomes; (2) to define meaningful intermediate outcomes at specific time points for different endotypes; (3) to describe recovery trajectories in the absence of limitations to care; (4) to harness big data and develop analytic methods to prognosticate more accurately; (5) to identify key elements and processes for communicating prognostic uncertainty over time; (6) to identify health care delivery models that facilitate recovery and recovery science; and (7) to advocate for changes in the health care delivery system needed to advance recovery science and implement already-known best practices.

Conclusion: This report summarizes the current research available to inform the proposed research needs, articulates key elements within each area, and discusses the goals and advances in recovery science and care anticipated by successfully addressing these needs.
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http://dx.doi.org/10.1007/s12028-021-01289-yDOI Listing
July 2021

Proceedings of the First Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness.

Neurocrit Care 2021 07 8;35(Suppl 1):4-23. Epub 2021 Jul 8.

Department of Neurology, New York Medical College, Valhalla, NY, USA.

Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified.
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http://dx.doi.org/10.1007/s12028-021-01260-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8264966PMC
July 2021

Disorders of Consciousness in Hospitalized Patients with COVID-19: The Role of the Systemic Inflammatory Response Syndrome.

Neurocrit Care 2021 Jun 28. Epub 2021 Jun 28.

Division of Critical Care Neurology, Department of Neurology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.

Background: Prevalence and etiology of unconsciousness are uncertain in hospitalized patients with coronavirus disease 2019 (COVID-19). We tested the hypothesis that increased inflammation in COVID-19 precedes coma, independent of medications, hypotension, and hypoxia.

Methods: We retrospectively assessed 3203 hospitalized patients with COVID-19 from March 2 through July 30, 2020, in New York City with the Glasgow Coma Scale and systemic inflammatory response syndrome (SIRS) scores. We applied hazard ratio (HR) modeling and mediation analysis to determine the risk of SIRS score elevation to precede coma, accounting for confounders.

Results: We obtained behavioral assessments in 3203 of 10,797 patients admitted to the hospital who tested positive for SARS-CoV-2. Of those patients, 1054 (32.9%) were comatose, which first developed on median hospital day 2 (interquartile range [IQR] 1-9). During their hospital stay, 1538 (48%) had a SIRS score of 2 or above at least once, and the median maximum SIRS score was 2 (IQR 1-2). A fivefold increased risk of coma (HR 5.05, 95% confidence interval 4.27-5.98) was seen for each day that patients with COVID-19 had elevated SIRS scores, independent of medication effects, hypotension, and hypoxia. The overall mortality in this population was 13.8% (n = 441). Coma was associated with death (odds ratio 7.77, 95% confidence interval 6.29-9.65) and increased length of stay (13 days [IQR 11.9-14.1] vs. 11 [IQR 9.6-12.4]), accounting for demographics.

Conclusions: Disorders of consciousness are common in hospitalized patients with severe COVID-19 and are associated with increased mortality and length of hospitalization. The underlying etiology of disorders of consciousness in this population is uncertain but, in addition to medication effects, may in part be linked to systemic inflammation.
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http://dx.doi.org/10.1007/s12028-021-01256-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238027PMC
June 2021

Electrocerebral Signature of Cardiac Death.

Neurocrit Care 2021 Dec 28;35(3):853-861. Epub 2021 Jun 28.

Department of Neurology, Neurological Institute, Columbia University Medical Center, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.

Background: Electroencephalography (EEG) findings following cardiovascular collapse in death are uncertain. We aimed to characterize EEG changes immediately preceding and following cardiac death.

Methods: We retrospectively analyzed EEGs of patients who died from cardiac arrest while undergoing standard EEG monitoring in an intensive care unit. Patients with brain death preceding cardiac death were excluded. Three events during fatal cardiovascular failure were investigated: (1) last recorded QRS complex on electrocardiogram (QRS), (2) cessation of cerebral blood flow (CBF) estimated as the time that blood pressure and heart rate dropped below set thresholds, and (3) electrocerebral silence on EEG (EEG). We evaluated EEG spectral power, coherence, and permutation entropy at these time points.

Results: Among 19 patients who died while undergoing EEG monitoring, seven (37%) had a comfort-measures-only status and 18 (95%) had a do-not-resuscitate status in place at the time of death. EEG occurred at the time of QRS in five patients and after QRS in two patients (cohort median - 2.0, interquartile range - 8.0 to 0.0), whereas EEG was seen at the time of CBF in six patients and following CBF in 11 patients (cohort median 2.0 min, interquartile range - 1.5 to 6.0). After CBF, full-spectrum log power (p < 0.001) and coherence (p < 0.001) decreased on EEG, whereas delta (p = 0.007) and theta (p < 0.001) permutation entropy increased.

Conclusions: Rarely may patients have transient electrocerebral activity following the last recorded QRS (less than 5 min) and estimated cessation of cerebral blood flow. These results may have implications for discussions around cardiopulmonary resuscitation and organ donation.
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http://dx.doi.org/10.1007/s12028-021-01233-0DOI Listing
December 2021

Predicting early recovery of consciousness after cardiac arrest supported by quantitative electroencephalography.

Resuscitation 2021 08 21;165:130-137. Epub 2021 Jun 21.

Department of Neurology, Columbia University Medical Center, New York, NY, USA. Electronic address:

Objective: To determine the ability of quantitative electroencephalography (QEEG) to improve the accuracy of predicting recovery of consciousness by post-cardiac arrest day 10.

Methods: Unconscious survivors of cardiac arrest undergoing daily clinical and EEG assessments through post-cardiac arrest day 10 were studied in a prospective observational cohort study. Power spectral density, local coherence, and permutation entropy were calculated from daily EEG clips following a painful stimulus. Recovery of consciousness was defined as following at least simple commands by day 10. We determined the impact of EEG metrics to predict recovery when analyzed with established predictors of recovery using partial least squares regression models. Explained variance analysis identified which features contributed most to the predictive model.

Results: 367 EEG epochs from 98 subjects were analyzed in conjunction with clinical measures. Highest prediction accuracy was achieved when adding QEEG features from post-arrest days 4-6 to established predictors (area under the receiver operating curve improved from 0.81 ± 0.04 to 0.86 ± 0.05). Prediction accuracy decreased from 0.84 ± 0.04 to 0.79 ± 0.04 when adding QEEG features from post-arrest days 1-3. Patients with recovery of command-following by day 10 showed higher coherence across the frequency spectrum and higher centro-occipital delta-frequency spectral power by days 4-6, and globally-higher theta range permutation entropy by days 7-10.

Conclusions: Adding quantitative EEG metrics to established predictors of recovery allows modest improvement of prediction accuracy for recovery of consciousness, when obtained within a week of cardiac arrest. Further research is needed to determine the best strategy for integration of QEEG data into prognostic models in this patient population.
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http://dx.doi.org/10.1016/j.resuscitation.2021.06.008DOI Listing
August 2021

Clinical review of cerebral venous thrombosis in the context of COVID-19 vaccinations: Evaluation, management, and scientific questions.

J Neurol Sci 2021 08 5;427:117532. Epub 2021 Jun 5.

Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA.

Background: Vaccine induced immune mediated thrombocytopenia or VITT, is a recent and rare phenomenon of thrombosis with thrombocytopenia, frequently including cerebral venous thromboses (CVT), that has been described following vaccination with adenovirus vaccines ChAdOx1 nCOV-19 (AstraZeneca) and Ad26.COV2·S Johnson and Johnson (Janssen/J&J). The evaluation and management of suspected cases of CVT post COVID-19 vaccination are critical skills for a broad range of healthcare providers.

Methods: A collaborative comprehensive review of literature was conducted among a global group of expert neurologists and hematologists.

Findings: Strategies for rapid evaluation and treatment of the CVT in the context of possible VITT exist, including inflammatory marker measurements, PF4 assays, and non-heparin anticoagulation.
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http://dx.doi.org/10.1016/j.jns.2021.117532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178065PMC
August 2021

COVID-19 neuropathology at Columbia University Irving Medical Center/New York Presbyterian Hospital.

Brain 2021 10;144(9):2696-2708

Department of Pathology and Cell Biology, Division of Neuropathology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, and the New York Presbyterian Hospital, New York, NY 10032, USA.

Many patients with SARS-CoV-2 infection develop neurological signs and symptoms; although, to date, little evidence exists that primary infection of the brain is a significant contributing factor. We present the clinical, neuropathological and molecular findings of 41 consecutive patients with SARS-CoV-2 infections who died and underwent autopsy in our medical centre. The mean age was 74 years (38-97 years), 27 patients (66%) were male and 34 (83%) were of Hispanic/Latinx ethnicity. Twenty-four patients (59%) were admitted to the intensive care unit. Hospital-associated complications were common, including eight patients (20%) with deep vein thrombosis/pulmonary embolism, seven (17%) with acute kidney injury requiring dialysis and 10 (24%) with positive blood cultures during admission. Eight (20%) patients died within 24 h of hospital admission, while 11 (27%) died more than 4 weeks after hospital admission. Neuropathological examination of 20-30 areas from each brain revealed hypoxic/ischaemic changes in all brains, both global and focal; large and small infarcts, many of which appeared haemorrhagic; and microglial activation with microglial nodules accompanied by neuronophagia, most prominently in the brainstem. We observed sparse T lymphocyte accumulation in either perivascular regions or in the brain parenchyma. Many brains contained atherosclerosis of large arteries and arteriolosclerosis, although none showed evidence of vasculitis. Eighteen patients (44%) exhibited pathologies of neurodegenerative diseases, which was not unexpected given the age range of our patients. We examined multiple fresh frozen and fixed tissues from 28 brains for the presence of viral RNA and protein, using quantitative reverse-transcriptase PCR, RNAscope® and immunocytochemistry with primers, probes and antibodies directed against the spike and nucleocapsid regions. The PCR analysis revealed low to very low, but detectable, viral RNA levels in the majority of brains, although they were far lower than those in the nasal epithelia. RNAscope® and immunocytochemistry failed to detect viral RNA or protein in brains. Our findings indicate that the levels of detectable virus in coronavirus disease 2019 brains are very low and do not correlate with the histopathological alterations. These findings suggest that microglial activation, microglial nodules and neuronophagia, observed in the majority of brains, do not result from direct viral infection of brain parenchyma, but more likely from systemic inflammation, perhaps with synergistic contribution from hypoxia/ischaemia. Further studies are needed to define whether these pathologies, if present in patients who survive coronavirus disease 2019, might contribute to chronic neurological problems.
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http://dx.doi.org/10.1093/brain/awab148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083258PMC
October 2021

Impacts of ABO-incompatible platelet transfusions on platelet recovery and outcomes after intracerebral hemorrhage.

Blood 2021 05;137(19):2699-2703

Department of Neurology, Vagelos College of Physicians and Surgeons.

Acute platelet transfusion after intracerebral hemorrhage (ICH) given in efforts to reverse antiplatelet medication effects and prevent ongoing bleeding does not appear to improve outcome and may be associated with harm. Although the underlying mechanisms are unclear, the influence of ABO-incompatible platelet transfusions on ICH outcomes has not been investigated. We hypothesized that patients with ICH who receive ABO-incompatible platelet transfusions would have worse platelet recovery (using absolute count increment [ACI]) and neurological outcomes (mortality and poor modified Rankin Scale [mRS 4-6]) than those receiving ABO-compatible transfusions. In a single-center cohort of consecutively admitted patients with ICH, we identified 125 patients receiving acute platelet transfusions, of whom 47 (38%) received an ABO-incompatible transfusion. Using quantile regression, we identified an association of ABO-incompatible platelet transfusion with lower platelet recovery (ACI, 2 × 103cells per μL vs 15 × 103cells per μL; adjusted coefficient β, -19; 95% confidence interval [CI], -35.55 to -4.44; P = .01). ABO-incompatible platelet transfusion was also associated with increased odds of mortality (adjusted odds ratio [OR], 2.59; 95% CI, 1.00-6.73; P = .05) and poor mRS (adjusted OR, 3.61; 95% CI, 0.97-13.42; P = .06); however, these estimates were imprecise. Together, these findings suggest the importance of ABO compatibility for platelet transfusions for ICH, but further investigation into the mechanism(s) underlying these observations is required.
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http://dx.doi.org/10.1182/blood.2020008381DOI Listing
May 2021

Incidence of Electrographic Seizures in Patients With COVID-19.

Front Neurol 2021 4;12:614719. Epub 2021 Feb 4.

Department of Neurology, Columbia University Irving Medical Center, Neurological Institute, New York Presbyterian Hospital, New York, NY, United States.

Critical illness and sepsis are commonly associated with subclinical seizures. COVID-19 frequently causes severe critical illness, but the incidence of electrographic seizures in patients with COVID-19 has been reported to be low. This retrospective case series assessed the incidence of and risks for electrographic seizures in patients hospitalized with COVID-19 who underwent continuous video electroencephalography monitoring (cvEEG) between March 1st, 2020 and June 30th, 2020. One hundred and twenty-two patients were initially identified who resulted SARS-CoV-2 nasopharyngeal RT-PCR swab positivity with any electroencephalography order placed in the EMR. Seventy-nine patients met study inclusion criteria: age ≥18 years, >1 h of cvEEG monitoring, and positive SARS-CoV-2 nasopharyngeal swab PCR. Six (8%) of the 79 patients suffered electrographic seizures (ES), three of whom suffered non-convulsive status epilepticus. Acute hyperkinetic movements were the most common reason for cvEEG in patients with ES (84%). None of the patients undergoing cvEEG for persistent coma (29% of all patients) had ES. Focal slowing (67 vs. 10%), sporadic interictal epileptiform discharges (EDs; 33 vs. 6%), and periodic/rhythmic EDs (67 vs. 1%) were proportionally more frequent among patients with electrographic seizures than those without these seizures. While 15% of patients without ES had generalized periodic discharges (GPDs) with triphasic morphology on EEG, none of the patients with ES had this pattern. Further study is required to assess the predictive values of these risk factors on electrographic seizure incidence and subsequent outcomes.
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http://dx.doi.org/10.3389/fneur.2021.614719DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890122PMC
February 2021

Dynamic Detection of Delayed Cerebral Ischemia: A Study in 3 Centers.

Stroke 2021 04 18;52(4):1370-1379. Epub 2021 Feb 18.

Department of Neurology (M.M., K.T., H.C., D.J.R., S.A., A.V., A.B., J.C., S.P.), Columbia University Irving Medical Center, New York.

Background And Purpose: Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage negatively impacts long-term recovery but is often detected too late to prevent damage. We aim to develop hourly risk scores using routinely collected clinical data to detect DCI.

Methods: A DCI classification model was trained using vital sign measurements (heart rate, blood pressure, respiratory rate, and oxygen saturation) and demographics routinely collected for clinical care. Twenty-two time-varying physiological measures were computed including mean, SD, and cross-correlation of heart rate time series with each of the other vitals. Classification was achieved using an ensemble approach with L2-regularized logistic regression, random forest, and support vector machines models. Classifier performance was determined by area under the receiver operating characteristic curves and confusion matrices. Hourly DCI risk scores were generated as the posterior probability at time using the Ensemble classifier on cohorts recruited at 2 external institutions (n=38 and 40).

Results: Three hundred ten patients were included in the training model (median, 54 years old [interquartile range, 45-65]; 80.2% women, 28.4% Hunt and Hess scale 4-5, 38.7% Modified Fisher Scale 3-4); 101 (33%) developed DCI with a median onset day 6 (interquartile range, 5-8). Classification accuracy before DCI onset was 0.83 (interquartile range, 0.76-0.83) area under the receiver operating characteristic curve. Risk scores applied to external institution datasets correctly predicted 64% and 91% of DCI events as early as 12 hours before clinical detection, with 2.7 and 1.6 true alerts for every false alert.

Conclusions: An hourly risk score for DCI derived from routine vital signs may have the potential to alert clinicians to DCI, which could reduce neurological injury.
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http://dx.doi.org/10.1161/STROKEAHA.120.032546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8247633PMC
April 2021

Frontotemporal EEG to guide sedation in COVID-19 related acute respiratory distress syndrome.

Clin Neurophysiol 2021 03 20;132(3):730-736. Epub 2021 Jan 20.

Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA. Electronic address:

Objective: To study if limited frontotemporal electroencephalogram (EEG) can guide sedation changes in highly infectious novel coronavirus disease 2019 (COVID-19) patients receiving neuromuscular blocking agent.

Methods: 98 days of continuous frontotemporal EEG from 11 consecutive patients was evaluated daily by an epileptologist to recommend reduction or maintenance of the sedative level. We evaluated the need to increase sedation in the 6 h following this recommendation. Post-hoc analysis of the quantitative EEG was correlated with the level of sedation using a machine learning algorithm.

Results: Eleven patients were studied for a total of ninety-eight sedation days. EEG was consistent with excessive sedation on 57 (58%) and adequate sedation on 41 days (42%). Recommendations were followed by the team on 59% (N = 58; 19 to reduce and 39 to keep the sedation level). In the 6 h following reduction in sedation, increases of sedation were needed in 7 (12%). Automatized classification of EEG sedation levels reached 80% (±17%) accuracy.

Conclusions: Visual inspection of a limited EEG helped sedation depth guidance. In a secondary analysis, our data supported that this determination may be automated using quantitative EEG analysis.

Significance: Our results support the use of frontotemporal EEG for guiding sedation in patients with COVID-19.
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http://dx.doi.org/10.1016/j.clinph.2021.01.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817418PMC
March 2021

Development of a brain-computer interface for patients in the critical care setting.

PLoS One 2021 22;16(1):e0245540. Epub 2021 Jan 22.

Department of Neurology, Columbia University Medical Center, New York, NY, United States of America.

Objective: Behaviorally unresponsive patients in intensive care units (ICU) are unable to consistently and effectively communicate their most fundamental physical needs. Brain-Computer Interface (BCI) technology has been established in the clinical context, but faces challenges in the critical care environment. Contrary to cue-based BCIs, which allow activation only during pre-determined periods of time, self-paced BCI systems empower patients to interact with others at any time. The study aims to develop a self-paced BCI for patients in the intensive care unit.

Methods: BCI experiments were conducted in 18 ICU patients and 5 healthy volunteers. The proposed self-paced BCI system analyzes EEG activity from patients while these are asked to control a beeping tone by performing a motor task (i.e., opening and closing a hand). Signal decoding is performed in real time and auditory feedback given via headphones. Performance of the BCI system was judged based on correlation between the optimal and the observed performance.

Results: All 5 healthy volunteers were able to successfully perform the BCI task, compared to chance alone (p<0.001). 5 of 14 (36%) conscious ICU patients were able to perform the BCI task. One of these 5 patients was quadriplegic and controlled the BCI system without any hand movements. None of the 4 unconscious patients were able to perform the BCI task.

Conclusions: More than one third of conscious ICU patients and all healthy volunteers were able to gain control over the self-paced BCI system. The initial 4 unconscious patients were not. Future studies will focus on studying the ability of behaviorally unresponsive patients with cognitive motor dissociation to control the self-paced BCI system.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245540PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822274PMC
June 2021

Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies.

Nat Rev Neurol 2021 03 14;17(3):135-156. Epub 2020 Dec 14.

Department of Neurology, Boston University School of Medicine, Boston, MA, USA.

Substantial progress has been made over the past two decades in detecting, predicting and promoting recovery of consciousness in patients with disorders of consciousness (DoC) caused by severe brain injuries. Advanced neuroimaging and electrophysiological techniques have revealed new insights into the biological mechanisms underlying recovery of consciousness and have enabled the identification of preserved brain networks in patients who seem unresponsive, thus raising hope for more accurate diagnosis and prognosis. Emerging evidence suggests that covert consciousness, or cognitive motor dissociation (CMD), is present in up to 15-20% of patients with DoC and that detection of CMD in the intensive care unit can predict functional recovery at 1 year post injury. Although fundamental questions remain about which patients with DoC have the potential for recovery, novel pharmacological and electrophysiological therapies have shown the potential to reactivate injured neural networks and promote re-emergence of consciousness. In this Review, we focus on mechanisms of recovery from DoC in the acute and subacute-to-chronic stages, and we discuss recent progress in detecting and predicting recovery of consciousness. We also describe the developments in pharmacological and electrophysiological therapies that are creating new opportunities to improve the lives of patients with DoC.
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http://dx.doi.org/10.1038/s41582-020-00428-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734616PMC
March 2021

Statewide Emergency Medical Services Protocols for Status Epilepticus Management.

Ann Neurol 2021 03 22;89(3):604-609. Epub 2020 Dec 22.

Department of Neurology, Alpert Medical School, Brown University, Providence, RI.

Although seizures are common in prehospital settings, standardized emergency medical services (EMS) treatment algorithms do not exist nationally. We examined nationwide variability in status epilepticus treatment by analyzing 33 publicly available statewide EMS protocols. All adult protocols recommend intravenous benzodiazepines (midazolam, n = 33; lorazepam, n = 23; diazepam, n = 24), 30 recommend intramuscular benzodiazepines (midazolam, n = 30; lorazepam, n = 8; diazepam, n = 3), and 27 recommend intranasal benzodiazepines (midazolam, n = 27; lorazepam, n = 3); pediatric protocols also frequently recommend rectal diazepam (n = 14). Recommended dosages vary widely, and first- and second-line agents are designated in only 18 and 2 states, respectively. Given this degree of variability, standardized national EMS guidelines are needed. ANN NEUROL 2021;89:604-609.
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http://dx.doi.org/10.1002/ana.25989DOI Listing
March 2021

Cerebrospinal Analysis in Patients With COVID-19.

Open Forum Infect Dis 2020 Nov 18;7(11):ofaa501. Epub 2020 Oct 18.

Department of Neurology, Columbia University Irving Medical Center (CUIMC)/New York Presbyterian Hospital, New York, New York, USA.

Background: Assessment of the impact of cerebrospinal fluid (CSF) analysis including investigation for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is essential for the optimization of patient care.

Methods: In this case series, we review patients diagnosed with SARS-CoV-2 undergoing lumbar puncture (LP) admitted to Columbia University Irving Medical Center (New York, NY, USA) from March 1 to May 26, 2020. In a subset of patients, CSF SARS-CoV-2 quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) testing is performed.

Results: The average age of 27 patients who underwent LP with definitive SARS-CoV-2 (SD) was 37.5 (28.7) years. CSF profiles showed elevated white blood cell counts and protein in 44% and 52% of patients, respectively. LP results impacted treatment decisions in 10 (37%) patients, either by change of antibiotics, influence in disposition decision, or by providing an alternative diagnosis. CSF SARS-CoV-2 qRT-PCR was performed on 8 (30%) patients, with negative results in all samples.

Conclusions: Among patients diagnosed with SARS-CoV-2, CSF results changed treatment decisions or disposition in over one-third of our patient cohort. CSF was frequently abnormal, though CSF SARS-CoV-2 qRT-PCR was negative in all samples. Further studies are required to define whether CSF SARS-CoV-2 testing is warranted in certain clinical contexts.
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http://dx.doi.org/10.1093/ofid/ofaa501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665724PMC
November 2020

The Modified Fisher Scale Lacks Interrater Reliability.

Neurocrit Care 2021 08 16;35(1):72-78. Epub 2020 Nov 16.

Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA.

Background: The modified Fisher scale (mFS) is a critical clinical and research tool for risk stratification of cerebral vasospasm. As such, the mFS is included as a common data element by the National Institute of Neurological Disorders and Stroke SAH Working Group. There are few studies assessing the interrater reliability of the mFS.

Methods: We distributed a survey to a convenience sample with snowball sampling of practicing neurointensivists and through the research survey portion of the Neurocritical Care Society Web site. The survey consisted of 15 scrollable CT scans of patients with SAH for mFS grading, two questions regarding the definitions of the scale criteria and demographics of the responding physician. Kendall's coefficient of concordance was used to determine the interrater reliability of mFS grading.

Results: Forty-six participants (97.8% neurocritical care fellowship trained, 78% UCNS-certified in neurocritical care, median 5 years (IQR 3-6.3) in practice, treating median of 80 patients (IQR 50-100) with SAH annually from 32 institutions) completed the survey. By mFS criteria, 30% correctly identified that there is no clear measurement of thin versus thick blood, and 42% correctly identified that blood in any ventricle is scored as "intraventricular blood." The overall interrater reliability by Kendall's coefficient of concordance for the mFS was moderate (W = 0.586, p < 0.0005).

Conclusions: Agreement among raters in grading the mFS is only moderate. Online training tools could be developed to improve mFS reliability and standardize research in SAH.
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http://dx.doi.org/10.1007/s12028-020-01142-8DOI Listing
August 2021

Electroencephalogram Monitoring in Critical Care.

Semin Neurol 2020 Dec 11;40(6):675-680. Epub 2020 Nov 11.

Department of Neurology, Columbia University, New York.

Seizures are common in critically ill patients. Electroencephalogram (EEG) is a tool that enables clinicians to provide continuous brain monitoring and to guide treatment decisions-brain telemetry. EEG monitoring has particular utility in the intensive care unit as most seizures in this setting are nonconvulsive. Despite the increased use of EEG monitoring in the critical care unit, it remains underutilized. In this review, we summarize the utility of EEG and different EEG modalities to monitor patients in the critical care setting.
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http://dx.doi.org/10.1055/s-0040-1719073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856834PMC
December 2020

Delayed reemergence of consciousness in survivors of severe COVID-19.

Neurocrit Care 2020 12 10;33(3):627-629. Epub 2020 Nov 10.

Feil Family Brain and Mind Research Institute, Weill Cornell Medical Center, New York, NY, USA.

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http://dx.doi.org/10.1007/s12028-020-01133-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654564PMC
December 2020

Novel approaches to prediction in severe brain injury.

Curr Opin Neurol 2020 12;33(6):669-675

Department of Neurology, Columbia University, New York, New York.

Purpose Of Review: Recovery after severe brain injury is variable and challenging to accurately predict at the individual patient level. This review highlights new developments in clinical prognostication with a special focus on the prediction of consciousness and increasing reliance on methods from data science.

Recent Findings: Recent research has leveraged serum biomarkers, quantitative electroencephalography, MRI, and physiological time-series to build models for recovery prediction. The analysis of high-resolution data and the integration of features from different modalities can be approached with efficient computational techniques.

Summary: Advances in neurophysiology and neuroimaging, in combination with computational methods, represent a novel paradigm for prediction of consciousness and functional recovery after severe brain injury. Research is needed to produce reliable, patient-level predictions that could meaningfully impact clinical decision making.
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http://dx.doi.org/10.1097/WCO.0000000000000875DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856833PMC
December 2020

Hypercoagulable viscoelastic blood clot characteristics in critically ill coronavirus disease 2019 patients and associations with thrombotic complications.

J Trauma Acute Care Surg 2021 01;90(1):e7-e12

From the Division of Critical Care and Hospitalist Neurology (D.J.R., H.K., A.B., S.A., S.P., J.C.), Department of Neurology, New York-Presbyterian Hospital and Vagelos College of Physicians and Surgeons, Columbia University; Department of Neurology (A.B.), Vagelos College of Physicians and Surgeons, Columbia University; Department of Neurological Surgery (N.Y., E.S.C.), New York-Presbyterian Hospital and Vagelos College of Physicians and Surgeons, Columbia University; and Department of Anesthesiology (K.E., G.W.), Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York.

Background: Critically ill coronavirus disease 2019 (COVID-19) patients have frequent thrombotic complications and laboratory evidence of hypercoagulability. The relationship of coagulation tests and thrombosis requires investigation to identify best diagnostic and treatment approaches. We assessed for hypercoagulable characteristics in critically ill COVID-19 patients using rotational thromboelastometry (ROTEM) and explored relationships of D-dimer and ROTEM measurements with thrombotic complications.

Methods: Critically ill adult COVID-19 patients receiving ROTEM testing between March and April 2020 were analyzed. Patients receiving therapeutic anticoagulation before ROTEM were excluded. Rotational thromboelastometry measurements from COVID-19 patients were compared with non-COVID-19 patients matched by age, sex, and body mass index. Intergroup differences in ROTEM measurements were assessed using t tests. Correlations of D-dimer levels to ROTEM measurements were assessed in COVID-19 patients who had available concurrent testing. Intergroup differences of D-dimer and ROTEM measurements were explored in COVID-19 patients with and without thrombosis.

Results: Of 30 COVID-19 patients receiving ROTEM, we identified hypercoagulability from elevated fibrinogen compared with non-COVID-19 patients (fibrinogen assay maximum clot firmness [MCF], 47 ± 13 mm vs. 20 ± 7 mm; mean intergroup difference, 27.4 mm; 95% confidence interval [CI], 22.1-32.7 mm; p < 0.0001). In our COVID-19 cohort, thrombotic complications were identified in 33%. In COVID-19 patients developing thrombotic complications, we identified higher D-dimer levels (17.5 ± 4.3 μg/mL vs. 8.0 ± 6.3 μg/mL; mean difference, 9.5 μg/mL; 95% CI, 13.9-5.1; p < 0.0001) but lower fibrinogen assay MCF (39.7 ± 10.8 mm vs. 50.1 ± 12.0 mm; mean difference, -11.2 mm; 95% CI, -2.1 to -20.2; p = 0.02) compared with patients without thrombosis. We identified negative correlations of D-dimer levels and ROTEM MCF in these patients (r = -0.61; p = 0.001).

Conclusion: We identified elevated D-dimer levels and hypercoagulable blood clot characteristics from increased fibrinogen on ROTEM testing in critically ill COVID-19 patients. However, we identified lower, albeit still hypercoagulable, ROTEM measurements of fibrinogen in COVID-19 patients with thrombotic complications compared with those without. Further work is required to externally validate these findings and to investigate the mechanistic drivers for these relationships to identify best diagnostic and treatment approaches for these patients.

Level Of Evidence: Epidemiologic, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002963DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8630999PMC
January 2021

Red Blood Cell Transfusions and Outcomes After Intracerebral Hemorrhage.

J Stroke Cerebrovasc Dis 2020 Dec 26;29(12):105317. Epub 2020 Sep 26.

Clinical and Translational Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, NY, United States. Electronic address:

Background: Low red blood cell (RBC) levels are associated with worse intracerebral hemorrhage (ICH) outcomes. However, relationships of RBC transfusions on ICH outcomes are unclear given the overlap of RBC transfusion, comorbidities, and disease severity. We investigated RBC transfusion relationships on ICH outcomes while accounting for comorbidities and disease severity.

Methods: ICH hospitalizations between 2002 and 2011 and RBC transfusion exposure were identified from the Nationwide Inpatient Sample using ICD-9-CM codes. Logistic regression was used to study the relationship between RBC transfusion on outcomes after adjusting for demographics, baseline comorbidities, and markers of disease severity. Additional sensitivity analyses stratified by comorbidity burden and disease severity were performed.

Results: Of 597,046 ICH hospitalizations, RBC transfusions were administered in 22,904 (4%). RBC transfusion was associated with higher odds of in-hospital mortality (adjusted OR: 1.22 [95%CI: 1.10-1.35]). In sensitivity analyses, RBC transfusions resulted in poor outcomes regardless of the comorbidity burden, but attenuation in this relationship was notable with lower comorbidities (adjusted OR 1.43 [95%CI: 1.34-1.51] vs 1.18 [95%CI: 1.10-1.29]). There were no associations of RBC transfusions with poor outcomes in hospitalizations without mechanical ventilation (adjusted OR 0.88 [95%CI: 0.83-1.13]) and in cases requiring ventriculostomy drains (adjusted OR 1.05 [95%CI: 0.97-1.10]).

Conclusions: In a large, nationally representative sample, RBC transfusion was associated with poor ICH outcomes. However, there were variations in this relationship based on comorbidities and disease severity. Additional prospective studies are required to assess direct risks and benefits from RBC transfusions in ICH.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686150PMC
December 2020

New-onset super-refractory status epilepticus: A case series of 26 patients.

Neurology 2020 10 17;95(16):e2280-e2285. Epub 2020 Sep 17.

From the Department of Neurology (E.M., N.M., R.L., K.D., J.C., K.T.T.), Columbia University, New York, NY; and Department of Neurology (A.A.), University of Miami, FL.

Objective: To better understand the heterogeneous population of patients with new-onset refractory status epilepticus (NORSE), we studied the most severe cases in patients who presented with new-onset super-refractory status epilepticus (NOSRSE).

Methods: We report a retrospective case series of 26 adults admitted to the Columbia University Irving Medical Center neurologic intensive care unit (NICU) from February 2009 to February 2016 with NOSRSE. We evaluated demographics, diagnostic studies, and treatment course. Outcomes were modified Rankin Scale score (mRS) at hospital discharge and most recent follow-up visit (minimum of 2 months post discharge), NICU and hospital length of stay, and long-term antiepileptic drug use.

Results: Of the 252 patients with refractory status epilepticus, 27/252 had NORSE and 26/27 of those had NOSRSE. Age was bimodally distributed with peaks at 27 and 63 years. The majority (96%) had an infectious or psychiatric prodrome. Etiology was cryptogenic in 73%, autoimmune in 19%, and infectious in 8%. Seven patients (27%) underwent brain biopsy, autopsy, or both; 3 (12%) were diagnostic (herpes simplex encephalitis, candida encephalitis, and acute demyelinating encephalomyelitis). On discharge, 6 patients (23%) had good or fair outcome (mRS 0-3). Of the patients with long-term follow-up data (median 9 months, interquartile range 2-22 months), 12 patients (71%) had mRS 0-3.

Conclusion: Among our cohort, nearly all patients with NORSE had NOSRSE. The majority were cryptogenic with few antibody-positive cases identified. Neuropathology was diagnostic in 12% of cases. Although only 23% of patients had good or fair outcome on discharge, 71% met these criteria at follow-up.
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http://dx.doi.org/10.1212/WNL.0000000000010787DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713780PMC
October 2020

Markers in Status Epilepticus Prognosis.

J Clin Neurophysiol 2020 Sep;37(5):422-428

Department of Neurology, Columbia University, New York, New York, U.S.A.; and.

Status epilepticus (SE) is a neurologic emergency with high morbidity and mortality. The assessment of a patient's prognosis is crucial in making treatment decisions. In this review, we discuss various markers that have been used to prognosticate SE in terms of recurrence, mortality, and functional outcome. These markers include demographic, clinical, electrophysiological, biochemical, and structural data. The heterogeneity of SE etiology and semiology renders development of prognostic markers challenging. Currently, prognostication in SE is limited to a few clinical scores. Future research should integrate clinical, genetic and epigenetic, metabolic, inflammatory, and structural biomarkers into prognostication models to approach "personalized medicine" in prognostication of outcomes after SE.
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http://dx.doi.org/10.1097/WNP.0000000000000761DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864547PMC
September 2020

Ketamine to treat super-refractory status epilepticus.

Neurology 2020 10 1;95(16):e2286-e2294. Epub 2020 Sep 1.

From the Departments of Neurology (A.A., C.A.D.-N., E.M., N.M., R.L., K.D., W.-T.C., C.R., A.V., D.R., S.A., S.P., J.C.) and Neurosurgery (E.S.C.), Columbia University, New York, NY; and Departments of Critical Care Medicine and Clinical Neurosciences (J.K.), University of Calgary, Canada.

Objective: To test ketamine infusion efficacy in the treatment of super-refractory status epilepticus (SRSE), we studied patients with SRSE who were treated with ketamine retrospectively. We also studied the effect of high doses of ketamine on brain physiology as reflected by invasive multimodality monitoring (MMM).

Methods: We studied a consecutive series of 68 patients with SRSE who were admitted between 2009 and 2018, treated with ketamine, and monitored with scalp EEG. Eleven of these patients underwent MMM at the time of ketamine administration. We compared patients who had seizure cessation after ketamine initiation to those who did not.

Results: Mean age was 53 ± 18 years and 46% of patients were female. Seizure burden decreased by at least 50% within 24 hours of starting ketamine in 55 (81%) patients, with complete cessation in 43 (63%). Average dose of ketamine infusion was 2.2 ± 1.8 mg/kg/h, with median duration of 2 (1-4) days. Average dose of midazolam was 1.0 ± 0.8 mg/kg/h at the time of ketamine initiation and was started at a median of 0.4 (0.1-1.0) days before ketamine. Using a generalized linear mixed effect model, ketamine was associated with stable mean arterial pressure (odds ratio 1.39, 95% confidence interval 1.38-1.40) and with decreased vasopressor requirements over time. We found no effect on intracranial pressure, cerebral blood flow, or cerebral perfusion pressure.

Conclusion: Ketamine treatment was associated with a decrease in seizure burden in patients with SRSE. Our data support the notion that high-dose ketamine infusions are associated with decreased vasopressor requirements without increased intracranial pressure.

Classification Of Evidence: This study provides Class IV evidence that ketamine decreases seizures in patients with SRSE.
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http://dx.doi.org/10.1212/WNL.0000000000010611DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713785PMC
October 2020

Clinical Impact of Hematoma Expansion in Left Ventricular Assist Device Patients.

World Neurosurg 2020 11 1;143:e384-e390. Epub 2020 Aug 1.

Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.

Background: Hematoma expansion (HE) is associated with poor outcome in patients with intracerebral hemorrhage (ICH), but the impact on patients with an left ventricular assist device (LVAD) is unknown. We aimed to define the occurrence of HE in the LVAD population and to determine the association between HE and mortality.

Methods: We performed a retrospective cohort study of LVAD patients and intentionally matched anticoagulated controls without LVAD admitted to Columbia University Irving Medical Center with ICH between 2008 and 2019. We compared HE occurrence between patients with an LVAD and those without an LVAD using regression modeling, adjusting for factors known to influence HE. We evaluated pump thrombosis following anticoagulation reversal. We examined the association between HE and hospital mortality using Poisson regression modeling adjusting for factors associated with poor outcome.

Results: Among 605 patients with an LVAD, we identified 28 patients with ICH meeting the study's inclusion criteria. Our LVAD ICH cohort was predominantly male (71%), with a mean age of 56 ± 10 years. The median baseline hematoma size was 20.1 mL (interquartile range [IQR], 8.6-46.9 mL), and the median ICH score was 1 (IQR, 1-2). There was no significant difference in occurrence of HE in LVAD patients and matched non-LVAD patients (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.4-4.2). There was an association between HE and in-hospital mortality in LVAD patients (adjusted OR, 4.8; 95% CI, 1.4-6.2).

Conclusions: HE occurrence appears to be similar in LVAD and non-LVAD patients. HE has a significant impact on LVAD ICH mortality, underscoring the importance of adequate coagulopathy reversal and blood pressure management in these patients.
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http://dx.doi.org/10.1016/j.wneu.2020.07.169DOI Listing
November 2020
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