Refractory status epilepticus (RSE) is an emergent and difficult neurologic problem that is not uncommon in clinical practice. In this report, we describe a 23-year-old man whose RSE was refractory to standard antiepileptic drugs and barbiturates; it was successfully terminated only with intravenous ketamine. In this report, we evaluated and discuss the clinical and electroencephalographic effects under ketamine. This case and the rare cases of ketamine experience in RSE reported in the literature show that ketamine is potentially effective to use when treating patients with RSE. Further clinical trials are warranted, however.

Background/Aims: Intravenous tissue plasminogen activator (tPA) treatment is recommended in acute stroke within 3 h of onset; however, the benefit of its use in the elderly remains uncertain. We assessed the safety and efficacy of tPA treatment in elderly patients. Methods: We recruited 97 elderly Chinese patients aged ≧80 years with cerebral ischemia presenting within 3 h of onset. Favorable outcomes were defined as discharge to home and modified Rankin Scale (mRS) ≤2 at discharge. Results: For moderate to severe patients (NIHSS ≧6), the baseline characteristics between the tPA (n = 30) and non-tPA (n = 41) group were not different. The proportion of patients discharged home was 56.7 and 61%, respectively (p = 0.72). For patients with baseline mRS ≤2, the frequency of discharged mRS ≤2 was not different (27.3% of the tPA group and 26.9% of the non-tPA group; p = 1.00). Symptomatic intracranial hemorrhage was 6.7 and 2.4%, respectively (p = 0.31). For minor stroke patients (NIHSS ≤5), tPA was not considered and the outcome of those discharged home and mRS ≤2 was 73 and 88%, respectively. Conclusion: Elderly patients can be treated safely with intravenous tPA, whereas our data did not support routine thrombolysis. Further randomized trials in the elderly are encouraged.

Figure 1. Trends of mean daily admissions of stroke between the first quarters of 2019 and 2020. (A) The rates of stroke and acute ischemic stroke (AIS) admissions decreased substantially over the first 3 months of 2020 (P<0.001 and P=0.03, respectively), but not in 2019 (P=0.13 and P=0.35, respectively). (B) The decrease of stroke admission rate in 2020 were consistently found in medical centers (P=0.007) and community hospitals (P=0.02).

Thyroidectomy significantly increased the long-term risk of OP. Younger patients, women, patients with comorbidities, and patients receiving chronic thyroxin treatment should be monitored for changes in postoperative bone density.