Altered mental status in the neurocritical care unit

Behrouz, Réza; Godoy, Daniel A.; Azarpazhooh, Mahmoud Reza; Napoli, Mario Di

doi:10.1016/j.jcrc.2015.07.021

Cited by 11 publications

(4 citation statements)

References 26 publications

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“…Regular delirium screening is, therefore, recommended by German and American guidelines in order to recognize and treat delirium early and prevent further complications [4,5]. However, evaluation of delirium may be more difficult in patients with neurological disorders, since several characteristics of delirium resemble a broad range of neurological signs and symptoms [6,7]. Studies investigating delirium in patients with stroke report an incidence rate of 10-48% [8].…”

Section: Introductionmentioning

confidence: 99%

Delirium Screening in Neurocritical Care and Stroke Unit Patients: A Pilot Study on the Influence of Neurological Deficits on CAM-ICU and ICDSC Outcome

et al. 2020

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Background/Objective: Delirium is a common complication in critically ill patients with a negative impact on hospital length of stay, morbidity, and mortality. Little is known on how neurological deficits affect the outcome of commonly used delirium screening tools such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) in neurocritical care patients. Methods: Over a period of 1 month, all patients admitted to a neurocritical care and stroke unit at a single academic center were prospectively screened for delirium using both CAM-ICU and ICDSC. Tool-based delirium screening was compared with delirium evaluation by the treating clinical team. Additionally, ICD-10 delirium criteria were assessed. Results: One hundred twenty-three patients with a total of 644 daily screenings were included. Twenty-three patients (18.7%) were diagnosed with delirium according to the clinical evaluation. Delirium incidence amounted to 23.6% (CAM-ICU) and 26.8% (ICDSC). Sensitivity and specificity of both screening tools were 66.9% and 93.3% for CAM-ICU and 69.9% and 93.9% for ICDSC, respectively. Patients identified with delirium by either CAM-ICU or ICDSC presented a higher proportion of neurological deficits such as impaired consciousness, expressive aphasia, impaired language comprehension, and hemineglect. Subsequently, generalized estimating equations identified a significant association between impaired consciousness (as indexed by Richmond Agitation and Sedation Scale) and a positive delirium assessment with both CAM-ICU and ICDSC, while impaired language comprehension and hemineglect were only associated with a positive CAM-ICU result. Conclusions: A positive delirium screening with both CAM-ICU and ICDSC in neurocritical care and stroke unit patients was found to be significantly associated with the presence of neurological deficits. These findings underline the need for a more specific delirium screening tool in neurocritical care patients.

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Section: Introductionmentioning

confidence: 99%

Delirium Screening in Neurocritical Care and Stroke Unit Patients: A Pilot Study on the Influence of Neurological Deficits on CAM-ICU and ICDSC Outcome

et al. 2020

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“…Altered mental status (AMS) is common in patients presenting to the emergency department, admitted to the hospital,[ 11 , 14 ] and in those admitted to the neurosurgical intensive care unit (NSICU). [ 1 , 3 ] Although the exact definition of AMS is vague, its presence necessitates evaluation to determine etiology. Because the differential diagnosis of AMS is broad and can include life-threatening causes, it is important to approach the workup systematically.…”

Section: Introductionmentioning

confidence: 99%

Efficacy of continuous electroencephalogram for the management of altered mental status in the neurosurgical intensive care unit

Ohene-Adjei

Begley

Temes

et al. 2023

Surgical Neurology International

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Background: Continuous electroencephalograms (cEEGs) are often used in the neurosurgical intensive care unit (NSICU) to detect subclinical seizures (SCSs) in patients with altered mental status (AMS). This retrospective study evaluated the efficacy of this approach for improving patient outcomes. Methods: We reviewed the records of 100 patients admitted to the NSICU between 2015 and 2020 who underwent continous electroencephalograms (cEEG) during workup of unexplained AMS. Patient outcomes were classified as positive (discharged), neutral (transfer of care), or negative (dead). Incidence of SCSs on cEEG and association with patient outcomes was analyzed with Chi-square analysis and relative risk (RR). Results: For the 99 included patients, median age was 62 years and 43% were female. About 15.2% had a known or newly diagnosed brain tumor. Outcomes were positive in 22 patients, neutral in four, and negative in 73. SCSs were detected in 15 patients, of whom 12 died, two were discharged, and one whose care was transferred. Chi-square association between SCS and outcome (P = 0.59) and RR of death associated with SCS diagnosis (1.1) was not significant. Conclusion: We found a lower incidence of SCSs (15.2%) than reported in the literature. In the absence of clinically evident seizures, continous cEEGs performed in the NSICU to determine the etiology of AMS did not yield an improvement in patient outcomes, and patients diagnosed and treated for SCS did not have statistically decreased risk of death. In summary, electroencephalogram monitoring for SCS is important but should not delay diagnosis and treatment of other, potentially life-threating etiologies of AMS.

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“…[1][2][3][4] However, identifying signs of stroke may be more difficult in patients with pre-existing alterations of consciousness or neurological impairment. [5][6][7] Computed brain tomography (brain CT) is an essential tool for diagnosing in-hospital stroke -either intracerebral haemorrhage (ICH) or acute ischaemic stroke (AIS). However, moving critically ill patients to the CT suite is not without risk.…”

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confidence: 99%

Prevalence and independent predictors of in-hospital stroke among patients who developed acute alteration of consciousness in the medical intensive care unit: A retrospective case-control study

Tongyoo

Viarasilpa

Vichutavate

et al. 2023

South Afr J Crit Care

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Background. In-hospital stroke is a serious event, associated with poor outcomes and high mortality. However, identifying signs of stroke may be more difficult in critically ill patients. Objectives. This study investigated the prevalence and independent predictors of in-hospital stroke among patients with acute alteration of consciousness in the medical intensive care unit (MICU) who underwent subsequent brain computed tomography (CT). Methods. This retrospective study enrolled eligible patients during the period 2007 - 2017. The alterations researched were radiologically confirmed acute ischaemic stroke (AIS) and intracerebral haemorrhage (ICH). Results. Of 4 360 patients, 113 underwent brain CT. Among these, 31% had AIS, while 15% had ICH. They had higher diastolic blood pressures and arterial pH than non-stroke patients. ICH patients had higher mean (standard deviation (SD) systolic blood pressures (152 (48) v. 129 (25) mmHg; p=0.01), lower mean (SD) Glasgow Coma Scale scores (4 (3) v. 7 (4); p=0.004), and more pupillary abnormalities (75% v. 9%; p<0.001) than AIS patients. AIS patients were older (65 (18) v. 57 (18) years; p=0.03), had more hypertension (60% v. 39%; p=0.04), and more commonly presented with the Babinski sign (26% v. 9%; p=0.04). Multivariate analysis found that pupillary abnormalities independently predicted ICH (adjusted odds ratio (aOR) 26.9; 95% CI 3.7 - 196.3; p=0.001). The Babinski sign (aOR 5.1; 95% CI 1.1 - 23.5; p=0.04) and alkalaemia (arterial pH >7.4; aOR 3.6; 95% CI 1.0 - 12.3; p=0.05) independently predicted AIS. Conclusions. Forty-six percent of the cohort had ICH or AIS. Both conditions had high mortality. The presence of pupillary abnormalities predicts ICH, whereas the Babinski sign and alkalaemia predict AIS.

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Altered mental status in the neurocritical care unit

Cited by 11 publications

References 26 publications

Delirium Screening in Neurocritical Care and Stroke Unit Patients: A Pilot Study on the Influence of Neurological Deficits on CAM-ICU and ICDSC Outcome

Delirium Screening in Neurocritical Care and Stroke Unit Patients: A Pilot Study on the Influence of Neurological Deficits on CAM-ICU and ICDSC Outcome

Efficacy of continuous electroencephalogram for the management of altered mental status in the neurosurgical intensive care unit

Prevalence and independent predictors of in-hospital stroke among patients who developed acute alteration of consciousness in the medical intensive care unit: A retrospective case-control study

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