Abstract: Background: Myasthenic crisis (MC) requiring mechanical ventilation (MV) is a rare and serious complication of myasthenia gravis. Here we analyzed the frequency of performed tracheostomies, risk factors correlating with a tracheostomy, as well as the impact of an early tracheostomy on ventilation time and ICU length of stay (LOS) in MC. Methods: Retrospective chart review on patients treated for MC in 12 German neurological departments between 2006 and 2015 to assess demographic/diagnostic data, rates and timing of tracheostomy and outcome. Results: In 107 out of 215 MC (49.8%), a tracheostomy was performed. Patients without tracheostomy were more likely to have an early-onset myasthenia gravis (27 [25.2%] vs 12 [11.5%], p = 0.01). Patients receiving a tracheostomy, however, were more frequently suffering from multiple comorbidities (20 [18.7%] vs 9 [8.3%], p = 0.03) and also the ventilation time (34.4 days ± 27.7 versus 7.9 ± 7.8, p 0.0001) and ICU-LOS (34.8 days ± 25.5 versus 12.1 ± 8.0, p 0.0001) was significantly longer than in non-tracheostomized patients. Demographics and characteristics of the course of the disease up to the crisis were not significantly different between patients with an early (within 10 days) compared to a late tracheostomy. However, an early tracheostomy correlated with a shorter duration of MV at ICU (26.2 days ± 18.1 versus 42.0 ± 33.1, p = 0.006), and ICU-LOS (26.2 days ± 14.6 versus 42.3 ± 33.0, p = 0.003).

Background: The optimal imaging strategy for selecting candidates for mechanical thrombectomy (MT) remains a matter of debate as its impact on clinical outcome is largely unknown from randomized trials. This study aimed to compare the clinical outcome of MT patients after selection by computed tomography (CT) or magnetic resonance imaging (MRI).Methods: Prospective MT registry data from a large comprehensive stroke center (CSC) was analyzed in anterior circulation LVO patients. Primary endpoint was modified Rankin Scale (mRS, 0-2 vs. 3-6) after 90 days in CT/CTA- (CT group) versus MRI- (MRI group) patients hypothesizing equivalence. Secondary endpoints included workflow times. Subgroup analyses compared directly admitted (mothership) and transferred (drip-and-ship) patients.Results: In 305 MT patients, clinical outcome was not equivalent between imaging groups (odds ratio for mRS 3-6, 0.58 uf05b95% CI, 0.352-0.955uf05d, favoring MRI). A trend towards more favorable outcome in MRI (42.3%) compared to CT group (32.6%; p=0.082) was noted which showed significance in mothership subgroup (48.9% vs. 28%, p=0.023). In hospital workflow times at CSC were equal in mothership patients between CT and MRI groups (door to first angiographic series, 107.5 min versus 109.5 min [p=0.445]; door to recanalization, 148.5 min versus 159 min [p=0.259]). In drip-and-ship patients, second imaging at CSC compared to direct transfer to MT did not change favorable outcome irrespective of utilized imaging modality (p=0.6-0.9).Conclusion: Functional outcome was not equivalent between CT- and MRI-selected MT patients. Overall, MRI selection showed a trend for more favorable outcome which was significant in mothership patients. MRI did not significantly prolong in-hospital workflow.

Abstract: Background Acute symptomatic epileptic seizures are frequently seen in neurocritical care. To prevent subsequent unprovoked seizures, long-term treatments with antiseizure medications are often initiated although supporting evidence is lacking. This study aimed at prospectively assessing the risk of unprovoked seizure relapse with respect to the use of antiseizure medications. It was hypothesized that after a first acute symptomatic seizure of structural etiology, the cumulative 12-month risk of unprovoked seizure relapse is ≤ 25%. Methods Inclusion criteria were age ≥ 18 and acute symptomatic first-ever epileptic seizure; patients with status epilepticus were excluded. Using telephone and mail interviews, participants were followed for 12 months after the acute symptomatic first seizure. Primary endpoint was the occurrence and timing of a first unprovoked seizure relapse. In addition, neuro-intensivists in Germany were interviewed about their antiseizure treatment strategies through an anonymous online survey. Results Eleven of 122 participants with structural etiology had an unprovoked seizure relapse, resulting in a cumulative 12-month risk of 10.7% (95%CI, 4.7%-16.7%). None of 19 participants with a non-structural etiology had a subsequent unprovoked seizure. Compared to structural etiology alone, combined infectious and structural etiology was independently associated with unprovoked seizure relapse (OR 11.1; 95%CI, 1.8-69.7). Median duration of antiseizure treatment was 3.4 months (IQR 0-9.3). Seven out of 11 participants had their unprovoked seizure relapse while taking antiseizure medication; longer treatment durations were not associated with decreased risk of unprovoked seizure relapse. Following the non-representative online survey, most neuro-intensivists consider 3 months or less of antiseizure medication to be adequate. Conclusions Even in case of structural etiology, acute symptomatic seizures bear a low risk of subsequent unprovoked seizures. There is still no evidence favoring long-term treatments with antiseizure medications. Hence, individual constellations with an increased risk of unprovoked seizure relapse should be identified, such as central nervous system infections causing structural brain damage. However, in the absence of high-risk features, antiseizure medications should be discontinued early to avoid overtreatment