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Clinical studies have demonstrated that administration of first-line benzodiazepine treatment within 10 minutes of seizure onset for pediatric patients with refractory convulsive status epilepticus is associated with lessened seizure duration, but it is not known whether treatment delay is associated with major adverse outcomes. In a multicenter observational study, Gaínza-Lein and coauthors included 218 pediatric patients from 11 tertiary hospitals. Seventy-four patients received first-line treatment within 10 minutes of seizure onset, and 144 received delayed treatment. Late treatment was associated with an increased need for continuous infusions, longer convulsive duration, more frequent hypotension, and death. Editorial perspective is provided by Patel.
Outcomes of guideline-concordant stroke care are measured by most health care organizations, but outcomes for patients with minor stroke and transient ischemic attack are often excluded from these quality measurements. Bravata and coauthors assessed 10 elements of care (5 preventive therapies and 5 diagnostic metrics) across the Veterans Health Administration system nationwide in a cohort study including 8201 veteran patients with transient ischemic attack or minor stroke. Veterans Health Administration adherence for all metrics was good, but opportunities were identified to improve care quality (eg, timing of neurology consultation, electrocardiography, carotid artery imaging, and statin prescription after discharge), particularly for patients who were discharged from the emergency department compared with patients who were admitted to the hospital. Kernan provides editorial perspective.
Neurological symptoms of carbon monoxide poisoning can appear not only immediately but also occasionally 2 to 6 weeks after successful resuscitation, but there is no reliable method to determine delayed neurological sequelae in advance. Jeon and coauthors conducted a registry-based observational study in a university setting in Seoul, Korea, including 387 patients who underwent diffusion-weighted imaging at an emergency department between 2011 and 2015. Seventy-seven patients had globus pallidus lesions, 13 had diffuse lesions, and 57 had focal lesions; delayed neurological sequelae occurred in 101 patients. The presence of acute brain lesions on initial imaging was significantly associated with the development of delayed neurological sequelae, indicating that diffusion-weighted imaging could be used to identify patients who may be at risk for delayed neurological symptoms.
Although endovascular therapy is the standard-of-care treatment for some patients with acute ischemic stroke, it is not clear if general anesthesia or conscious sedation during endovascular therapy is preferable. In the GOLIATH trial, a single-center, prospective, randomized trial, Simonsen and coauthors assessed 128 patients with acute ischemic stroke who received endovascular therapy under either general anesthesia (n = 65) or conscious sedation (n = 63). Diffusion-weighted magnetic resonance imaging was performed at presentation and 48 to 72 hours after endovascular therapy to measure infarct growth; no significant difference in infarct growth was found between the groups, but patients in the general anesthesia group had better 90-day functional outcomes.
Continuing Medical Education
Highlights. JAMA Neurol. 2018;75(4):391. doi:10.1001/jamaneurol.2017.2631