Objectives: To evaluate the effect of intensive care unit continuous EEG (cEEG) monitoring on inpatient mortality, hospital charges, and length of stay.Methods: A retrospective cross-sectional study was conducted using the Nationwide Inpatient Sample, a dataset representing 20% of inpatient discharges in nonfederal US hospitals. Adult discharge records reporting mechanical ventilation and EEG (routine EEG or cEEG) were included. cEEG was compared with routine EEG alone in association with the primary outcome of in-hospital mortality and secondary outcomes of total hospital charges and length of stay. Demographics, hospital characteristics, and medical comorbidity were used for multivariate adjustments of the primary and secondary outcomes.Results: A total of 40,945 patient discharges in the weighted sample met inclusion criteria, of which 5,949 had reported cEEG. Mechanically ventilated patients receiving cEEG were younger than routine EEG patients (56 vs 61 years; p , 0.001). There was no difference in the 2 groups in income or medical comorbidities. cEEG was significantly associated with lower in-hospital mortality in both univariate (odds ratio 5 0.54, 95% confidence interval 0.45-0.64; p , 0.001) and multivariate (odds ratio 5 0.63, 95% confidence interval 0.51-0.76; p , 0.001) analyses. There was no significant difference in costs or length of stay for patients who received cEEG relative to those receiving only routine EEG. Sensitivity analysis showed that adjusting for diagnosis-related groups (DRGs) for any neurologic diagnoses, DRGs for neurologic procedures, and specific DRGs for epilepsy/ convulsions did not substantially alter the association of cEEG with reduced inpatient mortality.Conclusions: cEEG is favorably associated with inpatient survival in mechanically ventilated patients, without adding significant charges to the hospital stay. Continuous EEG (cEEG) is increasingly utilized in critically ill patients with abnormal neurologic function. cEEG can detect convulsive and nonconvulsive seizures, brain ischemia, and other disturbances as they occur, prompting adjustment of anticonvulsants 1,2 or interventions to reverse focal ischemia.3,4 For seizures, only cEEG can provide this diagnostic information; for detection of focal ischemia, cEEG may be more sensitive than imaging 5 and gives uninterrupted bedside appraisal. Encephalopathic patients may benefit from cEEG 6 even in the absence of known acute brain injury. 7The evidence for cEEG has focused on rates of seizure detection in specific patient populations, 8 and the significance of particular EEG patterns.9-11 Meaningful improvement in patient outcomes has yet to be demonstrated. 12,13The literature regarding costs, charges, or cost-effectiveness of cEEG is more limited. A singlecenter study showed that cEEG was responsible for only 1% of total hospital charges for From the Departments of Neurology (J.P.N.) and Health Services (L.N.),

Methods: A Choosing Wisely Working Group of 10 AAN members was formed to oversee the process and craft the evidence-based recommendations. AAN members were solicited for recommendations, the recommendations were sent out for external review, and the Working Group members (article authors) used a modified Delphi process to select their Top Five Recommendations. Results and recommendations:The Working Group submitted 5 neurologic recommendations to the AAN Practice Committee and Board of Directors; all 5 were approved by both entities in September 2012. Recommendation 1: Don't perform EEGs for headaches. Recommendation 2: Don't perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. Recommendation 3: Don't use opioids or butalbital for treatment of migraine, except as a last resort. Recommendation 4: Don't prescribe interferon-b or glatiramer acetate to patients with disability from progressive, nonrelapsing forms of multiple sclerosis. Recommendation 5: Don't recommend carotid endarterectomy for asymptomatic carotid stenosis unless the complication rate is low (,3%). Alzheimer disease, Parkinson disease, stroke, and multiple sclerosis affect approximately 15 million people and account for more than $290 billion in health care spending annually in the United States.

There are at least five types of alterations of consciousness that occur during epileptic seizures: auras with illusions or hallucinations, dyscognitive seizures, epileptic delirium, dialeptic seizures, and epileptic coma. Each of these types of alterations of consciousness has a specific semiology and a distinct pathophysiologic mechanism. In this proposal we emphasize the need to clearly define each of these alterations/loss of consciousness and to apply this terminology in semiologic descriptions and classifications of epileptic seizures. The proposal is a consensus opinion of experienced epileptologists, and it is hoped that it will lead to systematic studies that will allow a scientific characterization of the different types of alterations/loss of consciousness described in this article.

No abstract

The American Society of Neurophysiological Monitoring (ASNM) was founded in 1989 as the American Society of Evoked Potential Monitoring. From the beginning, the Society has been made up of physicians, doctoral degree holders, Technologists, and all those interested in furthering the profession. The Society changed its name to the ASNM and held its first Annual Meeting in 1990. It remains the largest worldwide organization dedicated solely to the scientifically-based advancement of intraoperative neurophysiology. The primary goal of the ASNM is to assure the quality of patient care during procedures monitoring the nervous system. This goal is accomplished primarily through programs in education, advocacy of basic and clinical research, and publication of guidelines, among other endeavors. The ASNM is committed to the development of medically sound and clinically relevant guidelines for the performance of intraoperative neurophysiology. Guidelines are formulated based on exhaustive literature review, recruitment of expert opinion, and broad consensus among ASNM membership. Input is likewise sought from sister societies and related constituencies. Adherence to a literature-based, formalized process characterizes the construction of all ASNM guidelines. The guidelines covering the Professional Practice of intraoperative neurophysiological monitoring were initially published January 24th, 2013, and subsequently that document has undergone review and revision to accommodate broad inter- and intra-societal feedback. This current version of the ASNM Professional Practice Guideline was fully approved for publication according to ASNM bylaws on February 22nd, 2018, and thus overwrites and supersedes the initial guideline.

Mapping should primarily guide tumor resection adjacent to the CST. Direct cortical stimulation-motor evoked potential is a useful predictor of deficits, but its value as a warning sign is limited because signal alterations were reversible in only approximately 60% of the present cases and irreversibility is a post hoc definition. The true safe mapping MT is lower than previously thought. The authors postulate a mapping MT of 1 mA or less where irreversible DCS-MEP changes and motor deficits regularly occur. Therefore, they recommend stopping tumor resection at an MT of 2 mA at the latest. The limited spatial and temporal coverage of contemporary mapping may increase error and may contribute to false, higher MTs.

Africa's history of neurology remains largely undiscovered and unwritten, except in countries like Egypt. The more modern history of neurology has been peppered with remarkable people such as Osuntokun in the latter part of the 20th century, followed by an unedifying gap in training and development in the specialty. Neurological morbidity, especially from human immunodeficiency virus (HIV) related neurological disease and stroke, is rising in much of the continent including Kenya. Kenya currently has six neurologists for a population of 30 million. (Contrast this with the demand to increase the number of neurologists in the UK, where over 300 consultant neurologists serve a population of 69 million, and it puts the situation neatly into perspective; figure.) 1 All of them work in Nairobi; four work at the Kenyatta National Hospital-the national referral and teaching hospital and the apex health institution of the public health service-but also in part-time private practice, and two work in private practice. Of the four public-health-service neurologists, three hold academic appointments with the University of Nairobi Medical School, and only one actually works for the hospital board (the equivalent of a UK National Health Service contract). I have been appointed by the hospital to develop my interest in clinical neurology and will become the seventh neurologist in the country when I return later this year. A Kenyan neurologist's long journey begins in medical school, with 5 years of undergraduate medical training, followed by a 1 year internship, leading to at least 2 years as a medical officer in a district general hospital. One can then apply for the formal internal medicine residency at the Kenyatta National Hospital, which takes a minimum of 3 years. This includes a research project-in addition to the clinical and academic workload-done over 2 years, which, in the case of the fledgling neurologist, is commonly on a topic of neurological interest (mine was on tuberculous meningitis, a problem of immense importance to the neurologist in an HIV and tuberculosis endemic region). At the end of this residency is an examination modelled on the Membership of the Royal College of Physicians (MRCP) assessment. My own initial training followed this pattern. There is no proper neurology training programme in Kenya. The trainee neurologist would thus seek a medical specialist or lecturer job at the Kenyatta National Hospital, which is the only institution with anything resembling

Temporary reversal of blood flow during TCAR is a safe maneuver and does not cause cerebral ischemia in the vast majority of patients, including those with contralateral carotid occlusion. Carotid stenting performed with reversed blood flow mitigates cerebral embolization and periprocedural stroke without concern for brain ischemia.