cEEG monitoring provides independent prognostic information in patients with poor-grade SAH, even after controlling for clinical and radiological findings. Unfavorable findings include periodic epileptiform discharges, electrographic status epilepticus, and the absence of sleep architecture.

We propose a comprehensive review of the subject of epileptiform and potentially harmful EEG patterns that lie on the interictal continuum (IIC) to help with therapeutic decision-making and target future research. This approach to "electro-physiological SE" encompasses five dimensions of the IIC: it characterizes a periodic or rhythmic pattern, not only regarding its ictal morphology and potential harm with secondary neuronal injury, but also addresses the "metabolic footprint," clinical repercussion, and epileptogenic potential. Recent studies have attempted to determine and qualify the ictal nature and the epileptogenic potential (i.e., risk of subsequent acute seizures) of particular IIC patterns and their intrinsic EEG characteristics. Others have correlated non-convulsive seizures with cognitive outcomes beyond mortality; non-convulsive seizures and sporadic, periodic, or rhythmic discharges to encephalopathy severity; and the spectrum of periodic or rhythmic patterns to measurable secondary brain injury. Equivocal periodic or rhythmic patterns on the IIC are frequently encountered in critical care neurology where clinicians often incorporate advanced neuroimaging, metabolic neuromonitoring, and anti-seizure drug short trials, in an effort to gauge these patterns. We propose portraying the IIC with a multiaxial graph to disambiguate each of these risks. Quantification along each axis may help calibrate therapeutic urgency. An adaptable scoring system assesses which quasi-ictal EEG patterns in this spectrum might reach the tipping point toward anti-seizure drug escalation, in neurocritically ill patients.

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Migraine with prolonged aura can mimic an acute ischemic stroke (AIS), as each may present with accompanying headache and focal neurologic deficits. During the acute episode, perfusion imaging like perfusion-weighted MRI (PWI) can show focal abnormalities corresponding to the neurologic deficits in both entities, making clinical distinction challenging, especially considering the time urgency of AIS treatment. In this case report, we discuss how we utilized hyperacute PWI in conjunction with clinical reasoning to propose the diagnosis of migraine-like headache with prolonged aura.Case report. A 46-year-old woman presented to the emergency department within 1 hour of sudden onset of bilateral tunnel vision. Over several minutes, this evolved into a right upper quadrant arc-shaped scotoma and then to right homonymous hemianopsia. She also developed a severe nonthrobbing right retro-orbital headache, which progressed to the bilateral occipital area with right face and arm paresthesias. Past history included allergy to iodinated contrast, Ehlers-Danlos type IV, and several years of frequent severe unilateral throbbing headaches with photophobia/phonophobia and nausea as a teenager. She had to miss school, had no aura, and had not been diagnosed with migraine, but her mother carried this diagnosis.Examination revealed right homonymous hemianopsia, decreased pinprick over the right face and arm, with no motor deficits, nuchal rigidity, or bruits (NIH Stroke Scale ϭ 3). Vital signs and noncontrast head CT were normal. To exclude AIS, we obtained an emergent gadolinium-enhanced MRI with diffusion-weighted imaging, PWI, and magnetic resonance angiogram (MRA) of the head and neck, 150 minutes after symptom onset (figure). The MRI did not demonstrate any area of reduced diffusion, vascular occlusion, abnormal arterial caliber, or dissection. Thrombolytic was not administered and the remaining magnetic resonance sequences revealed normal fluid-attenuated inversion recovery (FLAIR). After the MRI, the patient's headache severity increased, with development of photophobia, severe nausea, and vomiting. These were treated with metoclopramide and naproxen, with resolution of all symptoms except hemianopsia over the next hour. Meanwhile, the raw perfusion images were processed to provide segmented and thresholded maps, facilitating better quantitative and qualitative assessment of any perfusion abnormality. While relative cerebral blood flow (rCBF) and relative cerebral blood volume (rCBV) maps were near normal, mean transit time (MTT) was slightly prolonged in the left occipital lobe. This focal hypoperfusion was best appreciated on the maximum time to peak of the residue function (Tmax) map. Substantial territory exhibited a Tmax Ͼ4 seconds, but minimal territory had a delay of Ն6 seconds. Dilated pial vessels were seen over the same area on contrast-enhanced T1 (T1Cϩ), without any parenchymal or meningeal enhancement (figure). The patient's vision finally returned to normal 14 hours after onset and she subsequently remained asy...

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