Abnormal movements in critical care patients with brain injury: a diagnostic approach

Damage to the Endotracheal Tube Caused by Incessant Biting by an Unconscious Patient After Stroke: A Case Report

Endotracheal intubation, a procedure performed using an endotracheal tube (ETT), has been identified as one of the most viable and common methods of managing the airway and artificially supporting respiration. Patient consciousness is an essential factor that is directly linked to airway safety, and an acute drop in the level of consciousness might threaten the airway. A Glasgow Coma Scale score of less than 9/15 is an indication of the need to protect the airway by conducting the commonly known procedure of endotracheal intubation. In the current case report, we found an unusual cause of leakage in the ventilator tube that affected the tube integrity: the involuntary tube biting of a patient admitted to the intensive care unit due to low consciousness provoked by an ischemic stroke. This constitutes an interesting phenomenon that must be investigated further. Aside from deciphering the underlying subconscious event, mitigatory mechanisms should be deployed along with ETT to prevent the ventilator circuit from failing.

ENIGMA's simple seven: Recommendations to enhance the reproducibility of resting-state fMRI in traumatic brain injury

Resting state functional magnetic resonance imaging (rsfMRI) provides researchers and clinicians with a powerful tool to examine functional connectivity across large-scale brain networks, with ever-increasing applications to the study of neurological disorders, such as traumatic brain injury (TBI). While rsfMRI holds unparalleled promise in systems neurosciences, its acquisition and analytical methodology across research groups is variable, resulting in a literature that is challenging to integrate and interpret. The focus of this narrative review is to address the primary methodological issues including investigator decision points in the application of rsfMRI to study the consequences of TBI. As part of the ENIGMA Brain Injury working group, we have collaborated to identify a minimum set of recommendations that are designed to produce results that are reliable, harmonizable, and reproducible for the TBI imaging research community. Part one of this review provides the results of a literature search of current rsfMRI studies of TBI, highlighting key design considerations and data processing pipelines. Part two outlines seven data acquisition, processing, and analysis recommendations with the goal of maximizing study reliability and between-site comparability, while preserving investigator autonomy. Part three summarizes new directions and opportunities for future rsfMRI studies in TBI patients. The goal is to galvanize the TBI community to gain consensus for a set of rigorous and reproducible methods, and to increase analytical transparency and data sharing to address the reproducibility crisis in the field.

Continuous Electroencephalogram Evaluation of Paroxysmal Events in Critically Ill Patients: Diagnostic Yield and Impact on Clinical Decision Making

BACKGROUND

Continuous electroencephalogram (cEEG) monitoring has been widely used in the intensive care unit (ICU) for the evaluation of patients in the ICU with altered consciousness to detect nonconvulsive seizures. We investigated the yield of cEEG when used to evaluate paroxysmal events in patients in the ICU and assessed the predictors of a diagnostic findings. The clinical impact of cEEG was also evaluated in this study.

METHODS

We identified patients in the ICU who underwent cEEG monitoring (> 6 h) to evaluate paroxysmal events between January 1, 2018, and December 31, 2019. We extracted patient demographics, medical history, neurological examination, brain imaging results, and the description of the paroxysmal events that necessitated the monitoring. We dichotomized the cEEG studies into those that captured habitual nonepileptic events or revealed epileptiform discharges (ictal or interictal), i.e., those considered to be of positive diagnostic yield (Y +), and those studies that did not show those findings (negative diagnostic yield, Y -). We also assessed the clinical impact of cEEG by documenting changes in administered antiseizure medication (ASM) before and after the cEEG.

RESULTS

We identified 159 recordings that were obtained for the indication of paroxysmal events, of which abnormal movements constituted the majority (n = 123). For the remaining events (n = 36), descriptions included gaze deviations, speech changes, and sensory changes. Twenty-nine percent (46 of 159) of the recordings were Y + , including the presence of ictal or interictal epileptiform discharges (n = 33), and captured habitual nonepileptic events (n = 13). A history of epilepsy was the only predictor of the study outcome. Detection of abnormal findings occurred within 6 h of the recording in most patients (30 of 46, 65%). Overall, cEEG studies led to 49 (31%) changes in ASM administration. The changes included dosage increases or initiation of ASM in patients with epileptiform discharges (n = 28) and reduction or elimination of ASM in patients with either habitual nonepileptic events (n = 5) or Y - cEEG studies (n = 16).

CONCLUSIONS

Continuous electroencephalogram monitoring is valuable in evaluating paroxysmal events, with a diagnostic yield of 29% in critically ill patients. A history of epilepsy predicts diagnostic studies. Both Y + and Y - cEEG studies may directly impact clinical decisions by leading to ASMs changes.

Evaluating denoising strategies in resting-state functional magnetic resonance in traumatic brain injury (EpiBioS4Rx)

Resting-state functional MRI is increasingly used in the clinical setting and is now included in some diagnostic guidelines for severe brain injury patients. However, to ensure high-quality data, one should mitigate fMRI-related noise typical of this population. Therefore, we aimed to evaluate the ability of different preprocessing strategies to mitigate noise-related signal (i.e., in-scanner movement and physiological noise) in functional connectivity (FC) of traumatic brain injury (TBI) patients. We applied nine commonly used denoising strategies, combined into 17 pipelines, to 88 TBI patients from the Epilepsy Bioinformatics Study for Anti-epileptogenic Therapy clinical trial. Pipelines were evaluated by three quality control (QC) metrics across three exclusion regimes based on the participant's head movement profile. While no pipeline eliminated noise effects on FC, some pipelines exhibited relatively high effectiveness depending on the exclusion regime. Once high-motion participants were excluded, the choice of denoising pipeline becomes secondary - although this strategy leads to substantial data loss. Pipelines combining spike regression with physiological regressors were the best performers, whereas pipelines that used automated data-driven methods performed comparatively worse. In this study, we report the first large-scale evaluation of denoising pipelines aimed at reducing noise-related FC in a clinical population known to be highly susceptible to in-scanner motion and significant anatomical abnormalities. If resting-state functional magnetic resonance is to be a successful clinical technique, it is crucial that procedures mitigating the effect of noise be systematically evaluated in the most challenging populations, such as TBI datasets.

Oromandibular dystonia – A systematic review

Oromandibular dystonia (OMD) is a clinical problem which is commonly encountered in the practice of movement disorders. OMD results from a variety of genetic and acquired etiologies and can occur as an isolated manifestation, or as part of an isolated generalized or a combined dystonia syndrome. There are only very few systematic reviews on this condition which often causes significant disability. We review here the etiology, clinical features, diagnostic approach and management of OMD.

Characterization of Postanoxic Tonic Eyelid Opening: A Poorly Recognized Prognostic Sign

Background

Postanoxic myoclonus is a known poor prognostic sign, and other postanoxic spontaneous movements have been reported but poorly described. We aim to describe the electroclinical phenomenon of postanoxic eyelid openings in context of its possible prognostic value.

Methods

We collected clinical data on postcardiac arrest patients with suspicious eyelid movements noted on continuous EEG monitoring. The eyelid movements captured on the video were correlated with the EEG findings and final clinical outcome. Neuroimaging data were reviewed when available. We also conducted a thorough literature review on this topic.

Results

A total of 10 patients (5 females) with average age of 56.1 (±14.4) years were included. The mean cardiopulmonary resuscitation duration was 18.9 (±11.3) minutes. Postanoxic eyelid-opening movements occurred at variable intervals (0.5-570 seconds) in each individual. Close examination of eyelid opening (available in 6 patients) revealed them to be tonic movements, lasting an average of 3 (±0.8) seconds and always succeeded the onset of burst of EEG activity in a burst-suppression background. This is a transient phenomenon, lasting a median duration of 30 (interquartile range 7.75-36) hours. MRI findings in 3 patients demonstrated diffuse cortical ischemic injury with relative sparing of the brainstem. All patients died within 2-7 days following cardiac arrest.

Conclusions

Contrary to previous descriptions, the postanoxic tonic eyelid openings (PATEO) are repetitive but nonperiodic, nonmyoclonic movements. Their close and specific temporal correlation with the burst of EEG activity suggests that this could be considered an ictal phenomenon requiring an intact midbrain based on MRI findings.

Abnormal movements in hospitalized COVID-19 patients: A case series

BACKGROUND

Abnormal movements in Covid-19 patients have been reported with varying degree of frequency, prompting neurologic consultation and additional diagnostic evaluation. We sought to evaluate the frequency and etiology of abnormal movements among hospitalized Covid-19 patients undergoing neurologic consultation.

METHODS

We retrospectively analyzed the first 50 consecutive patients with confirmed Covid-19 hospitalized at our tertiary medical care center who underwent acute inpatient neurology consultation from March 2020 through May 2020. Indication for neurologic consultation and diagnostic studies performed were identified by electronic medical record review.

RESULTS

Of the 50 initial consultation requests, 11 (22.0%) patients were evaluated for abnormal movements (nine male and two female). Myoclonus was diagnosed in 6/11 (54.5%) patients. Additionally, two patients were diagnosed with seizures (confirmed on EEG in one), while two additional patients were diagnosed with tremor (physiologic and probable functional). A single case of serotonin syndrome was also identified.

CONCLUSION

Abnormal movements observed in hospitalized Covid-19 patients can have a wide range of etiologies and were a frequent initial indication for neurologic consultation. Myoclonus was the most frequent type of abnormal movement observed. Early clinical recognition and directed diagnostic work-up is essential for accurate diagnoses in these patients.

[Irreversible brain death-Part 2. Spinalization phenomena]

Spinal automatisms and reflexes, peripheral neurogenic and myogenic reactions are common in patients with irreversible brain death. They are therefore compatible and are even understood by experienced investigators as confirmation of irreversible brain death. This article provides an overview of the phenomenology of irreversible brain death and discusses it from a neuropathological perspective. Furthermore, irreversible brain death is described in order to distinguish it from pathological movements and motor reactions in comatose patients or patients with disturbed consciousness due to severe brain disorders.

Re-Establishing Solid Food Consumption in a Person With Traumatic Brain Injury and Extended Food Avoidance/Restriction Using a Multicomponent Behavioral Intervention

We describe and report the results of a multicomponent behavioral intervention for re-establishing solid food consumption in a 26-year-old woman with prolonged food avoidance and restriction which developed following a traumatic brain injury. The intervention was evaluated by direct measurement of daily meal consumption over a period of several months, including an extended follow-up, and resulted in successful resumption of oral feeding. A complicating paroxysmal movement disorder resolved during treatment as well and resolution of the presenting problem led to significant quality of life improvements. We discuss the relationship of the presenting symptoms to avoidant/restrictive food intake disorder and to food rejection behavior seen when substantial damage has occurred to the parietal lobe. The case illustrates the value of assessment-based, individualized intervention design and an integrated neurobehavioral case conceptualization.

Evaluation of Brain Death in Laying Hens During On-Farm Killing by Cervical Dislocation Methods or Pentobarbital Sodium Injection

This study investigated changes in the electroencephalograph (EEG) power spectrum as well as physiological and behavioral responses to on-farm killing via mechanical cervical dislocation (MCD), manual cervical dislocation (CD) or intravenous pentobarbital sodium administration in lightly anesthetized laying hens, to evaluate the welfare impact of each method. A mixed group of 44 white Leghorn and Smoky Joe laying hens (60 weeks-old) were anesthetized with isoflurane in oxygen and maintained at 1.5–2% isoflurane/O₂ until the killing method was applied. Birds were randomly assigned to one of three experimental groups on each trial day. The EEG was recorded bilaterally in a four-electrode montage. After recording a 5-min baseline, the killing method was applied and EEGs and other behavioral and physiological responses, including convulsions, gasping, cessation of body movements and feather erection were recorded for 5 min. Changes in EEG frequency bands (alpha, beta, delta, theta), median frequency (F50), 95% spectral edge frequency (F95), and total power (Ptot) were used to assess the quality of the on-farm killing event. Within 15 s after administration of pentobarbital sodium, there were significant decreases in mean frequency bands, increases in mean F50 and F95, and decreases in Ptot, suggesting brain death. In addition, birds presented a shorter latency to cessation of movement after pentobarbital sodium injection compared to MCD and CD (22 vs. 115 s and 136 s, respectively). There were significant increases in F95 and decreases in Ptot at 120 s after application of CD; and a concomitant decrease in the frequency bands at 135 s and isoelectric EEG at 171 ± 15 s. Changes consistent with brain death after MCD included isoelectric EEG at 207 ± 23 s and a significant decreases in some frequency bands at 300 s post-application. No other significant spectrum frequency changes were observed in the MCD group, suggesting brain death likely occurred near the 5-min endpoint. There was no clear association between behavioral, physiological, and EEG responses within CD and MCD treatments. The data demonstrate that pentobarbital sodium induced a rapid death with minimal behavioral and physiological responses regardless of strain of hens. In comparison, use of CD and MCD resulted in a slow onset of brain death in hens.

A Review of Tics Presenting Subsequent to Traumatic Brain Injury

Purpose of review

This review summarizes case reports of patients with tics emerging subsequent to traumatic brain injury (TBI), with respect to demographics, post-TBI symptoms, tic onset latency and topography, clinical history, neuroimaging results and treatment outcome.

Recent findings

Patients were 22 adults and 3 youth. Trauma onset appeared to fall mostly in adulthood. Two-thirds of patients were male and head trauma was related to motor vehicle accidents in most cases. Loss of consciousness was reported in just below half (48.0%) of cases. Associated physical and cognitive symptoms (e.g., impaired memory, reduced sensory perception, poor balance, muscle weakness, attention problems, aggression/impulsivity, obsessions and compulsions, depression and anxiety) were commonly reported. The latency between head trauma and tic onset varied, but generally ranged from one day post-trauma to approximately one year post-trauma. Sole presentation of motor tics was common, with rostral to caudal development of motor tics in other cases. Simple and/or complex vocal tics were present in several cases, often emerging after motor tics. Post-trauma obsessive-compulsive symptoms were noted in five cases (20.0%). A personal or family history of tics was reported in four cases. Damage to the basal ganglia, ventricular system, and temporal region was observed across ten patients (40.0%). Pharmacological intervention varied, with tic symptoms deemed to have significantly or somewhat improved in 12 cases (48.0%). A comparison of post-TBI symptoms in youth with head trauma history relative to those with peripheral injury suggests tic symptoms are not a common post-TBI symptom in youth.

Summary

Ultimately, there has been limited study on the link between traumatic brain injury and tic expression, and methodological issues preclude the ability to draw definitive conclusions regarding this relationship. Nevertheless, findings do suggest there may be heterogeneity in brain dysfunction associated with tic expression. Future case reports should utilize more systematic and thorough assessment of TBI and tics using validated measures, evaluate medication effects using single-case designs, and perform more longitudinal follow-up of cases with repeated neuroimaging.

An update on the recognition and treatment of non-convulsive status epilepticus in the intensive care unit

INTRODUCTION

Non-convulsive status epilepticus (NCSE) is a complex and diverse condition which is often an under-recognised entity in the intensive care unit. When NCSE is identified the optimal treatment strategy is not always clear. Areas covered: This review is based on a literature review of the key literature in the field over the last 5-10 years. The articles were selected based on their importance to the field by the authors. Expert commentary: This review discusses the complex situations when a neurological consultation may occur in a critical care setting and provides an update on the latest evidence regarding the recognition of NCSE and the decision making around determining the aggressiveness of treatment. It also considers the ictal-interictal continuum of conditions which may be met with, particularly in the era of continuous EEG, and provides an approach for dealing with these. Suggestions for how the field will develop are discussed.

Semiology of subtle motor phenomena in critically ill patients

PURPOSE

to investigate the semiology of subtle motor phenomena in critically ill patients, with- versus without nonconvulsive status epilepticus (NCSE).

METHODS

60 consecutive comatose patients, in whom subtle motor phenomena were observed in the intensive care unit (ICU), were analysed prospectively. The semiology of the subtle phenomena was described from video-recordings, blinded to all other data. For each patient, the type, location and occurrence-pattern/duration were described. EEGs recorded in the ICU were classified using the Salzburg criteria for NCSE.

RESULTS

only 23% (14/60) of the patients had NCSE confirmed by EEG. None of the semiological features could distinguish between patients with NCSE and those without. In both groups, the following phenomena were most common: discrete myoclonic muscle twitching and discrete tonic muscle activation. Besides these, automatisms and eye deviation were observed in both groups.

CONCLUSION

subtle motor phenomena in critically ill patients can raise the suspicion of NCSE. Nevertheless, EEG is needed to confirm the diagnosis, since none of the semiological features are specific.