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ObjectiveTo analyze rates of reported severe adverse events after immunization (sAEFI) attributed to SARS-CoV-2 vaccines in the United States (US) using safety surveillance data.MethodsObservational study of sAEFI reported to the vaccine adverse events reporting system (VAERS) between December 13, 2020, to December 13, 2021, and attributed to SARS-CoV-2 vaccination programs across all US states and territories. All sAEFI in conjunction with mRNA (BNT-162b2 or mRNA-1273) or adenovector (Ad26.COV2.S) vaccines were included. The 28-day crude cumulative rates for reported emergency department (ED) visits and sAEFI viz. hospitalizations, life-threatening events and deaths following SARS-CoV-2 vaccination were calculated. Incidence rate ratios (IRRs) of reported sAEFI were compared between mRNA and adenovector vaccines using generalized Poisson regression models.ResultsDuring the study period, 485 million SARS-CoV-2 vaccines doses were administered nationwide, and 88,626 sAEFI reported in VAERS. The 28-day crude cumulative reporting rates per 100,000 doses were 14.97 (95% confidence interval, 14.86–18.38) for ED visits, 5.32 (5.26–5.39) for hospitalizations, 1.72 (1.68–1.76) for life-threatening events, and 1.08 (1.05–1.11) for deaths. Females had two-fold rates for any reported AEFI compared to males, but lower adjusted IRRs for sAEFI. Cumulative rates per dose for reported sAEFI attributed to adenovector vaccine were 2–3-fold higher, and adjusted IRRs 1.5-fold higher than mRNA vaccines.ConclusionsOverall cumulative rates for reported sAEFI following SARS-CoV-2 vaccination in the US over 1 year were very low; single-dose adenovector vaccine had 1.5-fold higher adjusted rates for reported sAEFI, which may however equate with multiple-doses mRNA vaccine regimens. These data indicate absence of high risks of sAEFI following SARS-CoV-2 vaccines and support safety equipoise between mRNA and adenovector vaccines. Public health messaging of these data is critical to overcome heuristic biases. Furthermore, these data may support ongoing adenovector vaccine use, especially in low- and middle-income countries due to affordability, logistical and cold chain challenges.

The differential diagnosis of generalized weakness in ICU patients is quite broad. Although neuromuscular disorders are the most common causes of generalized weakness, a thorough evaluation is necessary to delineate the underlying cause of weakness. Biochemical studies, neuroimaging, and electrophysiologic studies help to delineate most of the common disorders associated with weakness. Prompt identification of a neurologic disorder and initiation of therapy speeds up recovery and reduces morbidity and mortality in these patients.

✓ The discovery of either a dermatomal cutaneous nevus or a spinal arteriovenous malformation (AVM) should raise the suspicion of Cobb syndrome. The Cobb syndrome is a neurocutaneous syndrome in which there are metameric cutaneous and spinal AVMs. The authors present the case of a patient with acute cervical myelopathy and subtle cutaneous hemangiomas in whom a cervical perimedullary fistula was discovered. They also acknowledge Harvey Cushing's contribution to the recognition of this syndrome.

The authors studied 24 patients admitted to the neurointensive care unit because of clinical deterioration to drowsiness or stupor and midline shift after complete middle cerebral artery infarction (coMCAI) stroke. Fourteen (58%) experienced further deterioration and either underwent hemicraniectomy or refused surgery and died. These patients were significantly more likely to be female (72% vs 20%) and to have additional vascular territorial infarction (72% vs 0%) on initial CT. These features may help to identify patients at high risk for further deterioration after coMCAI.

A stent graft was deployed to treat a postcarotid endarterectomy pseudoaneurysm in a 52-year-old man. One and a half years later, he developed asymptomatic extrusion of the stent graft. CT angiography showed stent extrusion with occlusion of the right carotid artery ([figure][1]). The stent was

OBJECTIVE To determine the incidence of cardiac troponin T (cTnT) elevation, electrocardiographic (ECG) changes, and arrhythmias in supratentorial intracerebral hemorrhage (ICH) and their association with early mortality. PATIENTS AND METHODS Patients with supratentorial ICHs admitted to Mayo Clinic, Rochester, Minn, from March 1998 to October 2003 were studied. We excluded moribund patients with ICHs who died within 12 hours of hospital admission. Cardiac troponin T levels measured on admission and day 2 were determined by a third-generation enzyme-linked immunosorbent assay. Continuous ECG monitoring was performed in all patients. Computed tomographic scans were graded and correlated with abnormal cardiac variables. RESULTS Peak levels of cTnT were elevated at 0.035 to 1.2 μg/L (mean ± SD, 0.27±0.38 μg/L) in 10 (20%) of 49 patients and were not associated with changes in creatine kinase MB fraction or ECG results. The cTnT levels did not correlate with location or side of hemorrhage or mortality at 30 days. Seventy (64%) of 110 patients displayed ECG abnormalities. The ECG changes did not correlate with the location or side of ICH, hydrocephalus, midline shift, or extension to the ventricles. CONCLUSION The cTnT elevations in survivors of acute ICH are frequent but without confirmatory ECG changes that suggest mild myocardial injury. One-month mortality is not influenced by such cTnT elevations. In addition, ECG abnormalities are common but likely benign in patients with supratentorial ICH who survive the initial insult.

Over the last few years, this 12-year-old boy had chewed off his lips and tongue, bitten his left arm, and eroded his nose by rubbing it on the floor …

The Glasgow Coma Scale (GCS) has been widely adopted. Failure to assess the verbal score in intubated patients and the inability to test brainstem reflexes are shortcomings. We devised a new coma score, the FOUR (Full Outline of UnResponsiveness) score. It consists of four components (eye, motor, brainstem, and respiration), and each component has a maximal score of 4. We prospectively studied the FOUR score in 120 intensive care unit patients and compared it with the GCS score using neuroscience nurses, neurology residents, and neurointensivists. We found that the interrater reliability was excellent with the FOUR score (kappa(w) = 0.82) and good to excellent for physician rater pairs. The agreement among raters was similar with the GCS (kappa(w) = 0.82). Patients with the lowest GCS score could be further distinguished using the FOUR score. We conclude that the agreement among raters was good to excellent. The FOUR score provides greater neurological detail than the GCS, recognizes a locked-in syndrome, and is superior to the GCS due to the availability of brainstem reflexes, breathing patterns, and the ability to recognize different stages of herniation. The probability of in-hospital mortality was higher for the lowest total FOUR score when compared with the lowest total GCS score.

Pituitary apoplexyis a potentially fatal neuroendocrinologic emergency that requires early clinical recognition, confirmation with specialized CT or MR imaging, and early medical and surgical intervention.

Neurotoxicity associated with calcineurin inhibitors cyclosporin A and tacrolimus is established. Sirolimus is a new agent related to tacrolimus, but its mechanism of action differs. The authors reviewed 202 transplant recipients treated with sirolimus from 2001 to 2004. They found no evidence of neurotoxicity with sirolimus therapy for up to 18 months (range, 15 days to 3 years). Sirolimus could be considered a substitute immunosuppressant for patients with cyclosporin A or tacrolimus neurotoxicity.

neurosurgical intensive care unit (NICU) and may only be diagnosed with simultaneous electrocardiography (EKG) and electroencephalography (EEG) monitoring. This 67-year-old woman presented to us 1 week after having undergone Guglielmi Detachable Coil embolization of a left supraclinoid internal carotid artery aneurysm. She had experienced two to three episodes of seizures along with severe bradycardia (heart rate 20 bpm). There was no history of cardiac illness or use of cardioactive drugs. On examination, she had a Glasgow Coma Scale score of 15 and mild conductive aphasia. Magnetic resonance studies revealed hyperintensities on T2-weighted images in the left temporal lobe and left basal ganglia, with the aneurysm abutting the temporal lobe on coronal images (Fig. 1). She was started on a regimen of sodium valproate. Simultaneous video EKG/EEG monitoring recorded a left temporal lobe seizure accompanied by severe bradycardia lasting 53 seconds (Fig. 2). The lowest heart rate recorded during monitoring was 22 bpm. The patient refused to undergo implantation of a cardiac pacemaker. She has experienced no other seizure during a 1-year follow-up period. Ictal arrhythmias presumably develop from the propagation of seizure activity to the central autonomic network (CAN), which regulates autonomic visceromotor output.1 The CAN consists of the insular cortex, amygdala, central nuclei, and portions of the hypothalamus. Cardiac pacing may be indicated because seizures are refractory to medication in 40% of patients and bradyarrhythmias are potentially fatal.2 Ictal bradycardia may occur in left hemisphere or temporal lobe seizures.3,4 To our knowledge, this is the first report of ictal bradycardia following endovascular therapy for an aneurysm. The contents of this report emphasize the importance of considering an ictal cause of bradycardia in patients in the NICU.

A man aged 67 years developed progressive drowsiness, left-sided weakness, and low-grade fever of 4-day duration. CT of the brain showed hypodensities in the right temporal and inferior frontal …