Treatment of Refractory Status Epilepticus With Continuous Intravenous Anesthetic Drugs: A Systematic Review

Importance

Multiple continuous intravenous anesthetic drugs (CIVADs) are available for the treatment of refractory status epilepticus (RSE). There is a paucity of data comparing the different types of CIVADs used for RSE.

Objective

To systematically review and compare outcome measures associated with the initial CIVAD choice in RSE in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Evidence Review

Data sources included English and non-English articles using Embase, MEDLINE, PubMed, and Web of Science (January 1994-June 2023) as well as manual search. Study selection included peer-reviewed studies of 5 or more patients and at least 1 patient older than 12 years with status epilepticus refractory to a benzodiazepine and at least 1 standard antiseizure medication, treated with continuously infused midazolam, ketamine, propofol, pentobarbital, or thiopental. Independent extraction of articles was performed using prespecified data items. The association between outcome variables and CIVAD was examined with an analysis of variance or χ2 test where appropriate. Binary logistic regressions were used to examine the association between outcome variables and CIVAD with etiology, change in mortality over time, electroencephalography (EEG) monitoring (continuous vs intermittent), and treatment goal (seizure vs burst suppression) included as covariates. Risk of bias was addressed by listing the population and type of each study.

Findings

A total of 66 studies with 1637 patients were included. Significant differences among CIVAD groups in short-term failure, hypotension, and CIVAD substitution during treatment were observed. Non-epilepsy-related RSE (vs epilepsy-related RSE) was associated with a higher rate of CIVAD substitution (60 of 120 [50.0%] vs 11 of 43 [25.6%]; odds ratio [OR], 3.11; 95% CI, 1.44-7.11; P = .006) and mortality (98 of 227 [43.2%] vs 7 of 63 [11.1%]; OR, 17.0; 95% CI, 4.71-109.35; P < .001). Seizure suppression was associated with mortality (OR, 7.72; 95% CI, 1.77-39.23; P = .005), but only a small subgroup was available for analysis (seizure suppression: 17 of 22 [77.3%] from 3 publications vs burst suppression: 25 of 98 [25.5%] from 12 publications). CIVAD choice and EEG type were not predictors of mortality. Earlier publication year was associated with mortality, although the observation was no longer statistically significant after adjusting SEs for clustering.

Conclusions and Relevance

Epilepsy-related RSE was associated with lower mortality compared with other RSE etiologies. A trend of decreasing mortality over time was observed, which may suggest an effect of advances in neurocritical care. The overall data are heterogeneous, which limits definitive conclusions on the choice of optimal initial CIVAD in RSE treatment.

Outcomes of endovascular thrombectomy in patients selected by computed tomography perfusion imaging - a matched cohort study comparing nonagenarians to younger patients

BACKGROUND

Endovascular thrombectomy (EVT) is efficacious for appropriately selected patients with large vessel occlusions (LVO) up to 24 hours from symptom onset. There is limited information on outcomes of nonagenarians, selected with computed tomography perfusion (CTP) imaging.

METHODS

We retrospectively analyzed data from a large academic hospital between December 2017 and October 2019. Patients receiving EVT for anterior circulation LVO were stratified into nonagenarian (≥90 years) and younger (<90 years) groups. We performed propensity score matching on 18 covariates. In the matched cohort we compared: primary outcome of inpatient mortality and secondary outcomes of successful reperfusion (TICI ≥2B), symptomatic intracranial hemorrhage (sICH), and functional independence. Subgroup analysis compared CTP predicted core volumes in nonagenarians with outcomes.

RESULTS

Overall, 214 consecutive patients (26 nonagenarians, 188 younger) underwent EVT. Nonagenarians were aged 92.8±2.9 years and younger patients were 74.5±13.5 years. Mortality rate was significantly greater in nonagenarians compared with younger patients (43.5% vs 10.4%, OR 9.33, 95% CI 2.88 to 47.97, P<0.0001) and a greater proportion of nonagenarians developed sICH (13.0% vs 3.0%, OR 6.00, 95% CI 1.34 to 55.20, P=0.02). There were no significant differences for successful reperfusion (P=1.00) or functional independence (P=0.75). Nonagenarians selected with smaller ischemic core volumes had decreased mortality rates (P=0.045).

CONCLUSIONS

Nonagenarians were noted to have greater mortality and sICH rates following EVT compared with matched younger patients, which may be ameliorated by selecting patients with smaller CTP core volumes. Nonagenarians undergoing EVT had similar rates of successful reperfusion and functional independence compared with the younger cohort.

Abstract TMP86: Telestroke Improves Guideline-Based Comprehensive Stroke Care: The TELECAST Trial

Introduction: Limited access to stroke specialist expertise produces disparities in inpatient stroke treatment. The impact of telestroke on the remote delivery of guideline-based inpatient stroke care is yet to be comprehensively studied. The TELECAST trial (NCT03672890) prospectively examined the impact of a 24-7 telestroke specialist service dedicated to inpatient acute stroke care spanning admission to discharge.

Methods: AHA stroke guidelines were used to derive outcome metrics in the following acute stroke inpatient care categories: diagnostic stroke evaluation (DSE), secondary stroke prevention (SSP), health screening and evaluation (HSE), and stroke education (SE). Adherence to AHA guidelines for stroke inpatients pre-telestroke (July 1, 2016-June 30, 2018) and post-telestroke intervention (July 1, 2018-June 30, 2019) were studied. The primary outcome was a composite score of all guideline-based stroke care. Secondary outcomes consisted of subcategory composite scores in DSE, SSP, HSE, and SE. Chi-squared tests were utilized to assess primary and secondary outcomes. Statistical analysis was performed using STATA 15.0.

Results: Following institution of a comprehensive inpatient telestroke service, overall adherence to guideline-based metrics improved (composite score: 85% vs 94%, p<0.01) as did adherence to DSE guidelines (subgroup score: 90 vs 95%, p<0.01). SSP, HSE, and SE subgroup scores were not significantly different. See Table 1.

Conclusion: The implementation of a 24-7 inpatient telestroke service improved adherence to AHA guidelines for inpatient acute stroke care. Dedicated inpatient telestroke specialist coverage may improve inpatient stroke care and reduce stroke recurrence in hospitals without access to stroke specialists.

Challenges Related to the Implementation of an EMS-Administered, Large Vessel Occlusion Stroke Score

Introduction

There is considerable interest in triaging victims of large vessel occlusion (LVO) strokes to comprehensive stroke centers. Timely access to interventional therapy has been linked to improved stroke outcomes. Accurate triage depends upon the use of a validated screening tool in addition to several emergency medical system (EMS)-specific factors. This study examines the integration of a modified Rapid Arterial oCcclusion Evaluation (mRACE) score into an existing stroke treatment protocol.

Methods

We performed a retrospective review of EMS and hospital charts of patients transported to a single comprehensive stroke center. Adult patients with an EMS provider impression of “stroke/TIA,” “CVA,” or “neurological problem” were included for analysis. EMS protocols mandated the use of the Cincinnati Prehospital Stroke Score (CPSS). The novel protocol authorized the use of the mRACE score to identify candidates for triage directly to the comprehensive stroke center. We calculated specificity and sensitivity for various stroke screens (CPSS and a mRACE exam) for the detection of LVO stroke. The score’s metrics were evaluated as a surrogate marker for a successful EMS triage protocol.

Results

We included 312 prehospital charts in the final analysis. The CPSS score exhibited reliable sensitivity at 85%. Specificity of CPSS for an LVO was calculated at 73%. For an mRACE score of five or greater, the sensitivity was 25%. Specificity for mRACE was calculated at 75%. The positive predictive value of the mRACE score for an LVO was estimated at 12.50%.

Conclusion

In this retrospective study of patients triaged to a single comprehensive stroke center, the addition of an LVO-specific screening tool failed to improve accuracy. Reliable triage of LVO strokes in the prehospital setting is a challenging task. In addition to statistical performance of a particular stroke score, a successful EMS protocol should consider system-based factors such as provider education and training. Study limitations can inform future iterations of LVO triage protocols.

Abstract WP289: Implementation of Secure Messaging System Reduces Response to Page Time in Telestroke Network

Introduction: Timeliness of a response to page by telestroke physicians is an important component in a telestroke network. Accrediting organizations such as the Joint Commission require telemedicine to be available within 20 minutes of the request. We implemented a secure messaging system to improve physician communication. We hypothesized that implementation of a secure messaging system would improve communication, reduce telestroke physician response to page and reduce door-to-needle (DTN) times compared to the previous pager-based system.

Methods: We reviewed data collected as part of our telestroke quality program. We compared response to page times for one year before and after initiation of the secure messaging system. Additionally, we compared DTN times during the same epochs.

Results: Seven hundred and sixty-five telestroke consults were completed in the year prior to implementation of the secure messaging system and 941 telestroke consults were completed in the year following implementation. Telestroke response to page time decreased significantly between pre ( mean rank 1005; median 4 min) and post ( mean rank 731 ; median 2 min) implementation of the secure messaging system ( U = 244,240 , p < .001, r = .28). A significantly greater percentage of telestroke neurologist response times occurred within 20 minutes when using secure messaging 936/941 (99.5%) compared to pagers, 751/765 (98.2%), χ 2 (1, N = 1706) = 6.46, p = .01, φ = .06. DTN was lower when using secure messaging (64 min) compared to the prior paging system (66 min), but this difference was not statistically significant ( p = .74).

Conclusions: In conclusion, implementation of a secure messaging system improved communication in our telestroke network and reduced telestroke response to page compared to our prior paging system. Implementation of the secure messaging system did not significantly reduce DTN times.

Bilateral independent periodic discharges are associated with electrographic seizures and poor outcome: A case-control study

OBJECTIVE

To determine the clinical correlates bilateral independent periodic discharges (BIPDs) and their association with electrographic seizures and outcome.

METHODS

Retrospective case-control study of patients with BIPDs compared to patients without periodic discharges ("No PDs") and patients with lateralized periodic discharges ("LPDs"), matched for age, etiology and level of alertness.

RESULTS

We included 85 cases and 85 controls in each group. The most frequent etiologies of BIPDs were stroke, CNS infections, and anoxic brain injury. Acute bilateral cerebral injury was more common in the BIPDs group than in the No PDs and LPDs groups (70% vs. 37% vs. 35%). Electrographic seizures were more common with BIPDs than in the absence of PDs (45% vs. 8%), but not than with LPDs (52%). Mortality was higher in the BIPDs group (36%) than in the No PDs group (18%), with fewer patients with BIPDs achieving good outcome (moderate disability or better; 18% vs. 36%), but not than in the LPDs group (24% mortality, 26% good outcome). In multivariate analyses, BIPDs remained associated with mortality (OR: 3.0 [1.4-6.4]) and poor outcome (OR: 2.9 [1.4-6.2]).

CONCLUSION

BIPDs are caused by bilateral acute brain injury and are associated with a high risk of electrographic seizures and of poor outcome.

SIGNIFICANCE

BIPDs are uncommon but their identification in critically ill patients has potential important implications, both in terms of clinical management and prognostication.