Electroencephalographic Findings in a Cohort of Egyptian Systemic Lupus Erythematosus Patients with Neuropsychiatric Manifestations

Background and Objective Neuropsychiatric manifestations are frequently reported in 75% of Systemic Lupus Erythematosus (SLE) patients and that varied from mild subtle signs: headache or mood disturbance to life threatening conditions: acute confusional state, major fits, stroke or transverse myelitis. Electroencephalography (EEG) was used to determine whether there is a lateralized pattern of electrophysiologic dysfunction in SLE patients or not. So, this study was done to describe EEG findings in a cohort of Egyptian SLE patients with Neuropsychiatric SLE (NPSLE), its possible correlation with any of the disease activity parameters and comparing them to patients with Non-NPSLE. Patients and Methods This case-control study was conducted on 60 SLE patients who fulfilled the 2015 ACR/SLICC Classification Criteria for SLE. They were classified into 2 groups: 30 patients with NPSLE as cases and 30 patients without NPSLE (Non-NPSLE) as controls. All patients were subjected to detailed medical history taking together with full clinical examination and calculations of SLE disease activity using the SLE disease activity index (SLEDAI) score. Laboratory investigations including CBC, ESR, CRP, BUN, creatinine, urine analysis, P/C ratio, C3, C4, Lupus Anticoagulant (LAC) and Anticardiolipin (ACL) antibodies and EEG were done for all patients. MRI brain was done for patients with NPSLE. Results There were 6 neuropsychiatric manifestations in the NPSLE group; the commonest was seizure disorders (43.3%), followed by psychosis (20.0%), cerebrovascular disease (16.7%), acute confusional state (13.3%), headache (10.0%) and lastly demyelinating syndrome (6.7%). SLEDAI score was higher in NPSLE group (Median=16) than nonNPSLE group (Median=4) (P < 0.01). ACL IgM positivity was higher in NPSLE group (P < 0.05). 53.3% of NPSLE group had abnormal MRI brain findings, the most common finding was periventricular white matter lesion (23.3%), followed by infarction (13.3%), subcortical white matter lesion and demyelinating lesion (6.7%). Lastly was sinus thrombosis, cerebral edema and encephalomalacia (3.3% each). 12 patients out of 30 (40.0%) with NPSLE had EEG abnormalities, while all 30 patients with non-NPSLE had no EEG abnormalities. The most common EEG abnormalities in NPSLE group were diffuse slowing (20.0%), followed by generalized epileptiform activity (13.3%), and lastly temporal epileptiform activity (6.7% each). 50% of patients with abnormal EEG had normal MRI. 13 patients out of 30 with NPSLE had seizure disorders (43.3%), 8 of them had abnormal EEG (61.5%). Conclusion Not all patients with NPSLE must have abnormal brain MRI or EEG. EEG is a useful assistant tool in diagnosing and studying the different manifestations of NPSLE especially seizure disorder and acute confusional state, but it cannot be used as a screening test alone for detecting NPSLE and must be supplemented by neuroimaging studies.

Evaluation and Management of Delirium

Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.

A Psychological Portrait of a Teenager in the Posttraumatic Confusional State

The Russian statistics demonstrate that in Russia, brain injuries are increasing every year what is particularly tragic if to speak about children. After traumatic brain injury (TBI), the process of consciousness restoration develops in stages. In Russian science, stages of mental recovery in adults are described by the neuropsychiatric group of researchers from Burdenko Institute of Neurosurgery. The authors have introduced the term amnestic confusion to designate the stage at which there is a possibility to have the verbal contact with amnestic defects and disorders of orientation in time and space. In foreign literature, this stage is defined as post-traumatic state of confused consciousness (PTCS). In children (adolescents), the state of confused consciousness after traumatic brain injury is met in about 80%. The aim of the study was to make a detailed description and phenomenological analysis of some psychological characteristics of the confused state in adolescents after brain injury what will add to the overall picture of medical and neuropsychological examinations. 62 teenagers in the confused consciousness state after TBI were taken into the study. The authors present their observations and analysis of such psychological phenomena as behavioral and emotional characteristics, social intelligence, gender and age identification.

Acute Confusional State Revealing Moyamoya Disease in the Emergency Department: A Rare Entity

A 54-year-old woman was admitted to the emergency department for an acute, fluctuating altered mental status and reduced perceptual awareness of her surroundings as well as disorganized thinking. Blood tests, including for drugs, were normal. A CT scan of the brain was normal. Magnetic resonance imaging and CT angiography of the supra-aortic vessels were both were consistent with moyamoya disease. The patient was hospitalized for further investigations.

Acute confusional state as a prognostic sign of COVID-19 large-vessel occlusion (LVO)

COVID-19 is well known for its respiratory symptoms, but severe presentations can alter haemostasis, causing acute end-organ damage with poor outcomes. Among its various neurological presentations, cerebrovascular events often present as small-vessel strokes. Although uncommon, in predisposed individuals, large-vessel occlusions (LVOs) can occur as a possible consequence of direct viral action (viral burden or antigenic structure) or virus-induced cytokine storm. Subtle presentations and complicated stroke care pathways continue to exist, delaying timely care. We present a unique case of COVID-19 LVO manifesting as an acute confusional state in an elderly man in April 2020. CT angiography revealed 'de novo' occlusions of the left internal carotid artery and proximal right vertebral artery, effectively blocking anterior and posterior circulations. Delirium can lead to inaccurate stroke scale assessments and prolong initiation of COVID-19 stroke care pathways. Future studies are needed to look into the temporal relationship between confusion and neurological manifestations.

Etiological Evaluation of Acute Confusional State in Elderly (≥60 Years) Patients

Background: Acute confusional state or delirium is a frequent cause of hospital admission in the elderly. It is characterized by an acute fluctuating impairment of cognitive functions and inattention. Recognition and prompt treatment is crucial to decrease the morbidity and mortality of hospitalized elderly patients. Aim of this study was to evaluate the distribution of common medical conditions related to acute confusional state among elderly hospitalized Patients. Methods: This was a cross sectional study. We enrolled 380 patients from different medicine wards in Dhaka Medical College Hospital. We included patients with acute confusional state/delirium of less than 7 days duration. The enrolled patients fulfilled the diagnostic criteria of an acute confusional state. A predesigned checklist was used for data collection. Head injury was excluded by history and CT scan of brain. Patients with preexisting illnesses, such as dementia, psychiatric illnesses and recurrent seizures, and any case of poisoning was excluded. All findings were noted and recorded. A written informed consent was taken from the attendant and relatives. Result: Among 380 patients, most of confusional state developed after the age of 65 years and the mean age was 69 +/-7.6 years. Associated medical conditions were uncontrolled hypertension (63.2%), fever & infection (41.6%), uncontrolled DM (36.6%), CVD (28.4%), CKD & electrolytes abnormalities (10.5%), joint diseases & pain (13.7%). Most of the patients used plyphormacy (76.6%) out of which antihypertensive (60%) were common. The mean duration of presentation was 6.1+/-0.6 days, and among all patients about 63.7% were improved, 29.50% was in persistant symptom of confusion and 6.8% of them died. Conclusion: Acute confusional state was common after 65 years. Uncontrolled hypertension, fever & infection, uncontrolled diabetes, CVD, CKD & electrolytes abnormalities and polypharmacy were found commonly in patients with acute confusional state. J MEDICINE JAN 2021; 22 (1) : 41-45