Urinary Sphincter Disorders of Neurological Origin: Prognostic Aspects in the Neurology Department of the Ignace Deen National Hospital

Introduction: Complications of Urinary sphincter disorders of neurological origin can be life threatening. The objective of this study was to describe the prognosis of urinary sphincter disorders during neurological conditions. Methods: This was a six-month analytical study conducted at the neurological unit of the Hôpital national Ignace Deen. Including patients with urinary sphincter disorders following a neurological condition;Chi-square, Fischer, and Student’s t-tests were used for variables with a p value less than 0.10 and then included in a logistic model with a significance level set at 0.05 and a 95% confidence interval. Results: We collected 1081 patients among whom, 324 presented, that is to say a frequency of 30%, which concerned subjects aged 57.3 ± 16.4 years with a slight female predominance 50.3%. Urinary incontinence (80.6%) was associated with complications such as urinary tract infection with a high proportion of cerebral damage (92.3%). HIV infection (P = 0.015), bedsores (P = 0.049), and inhalation pneumonia (P = 0.001) were the main poor prognostic factors. Conclusion: Urinary sphincter disorders are elements of poor prognosis, both vital and functional, concerning elderly subjects with a predominance of urinary incontinence. HIV infection, bedsores, pneumopathy are poor prognostic factors.

A case of atypical neurological symptoms and high cerebro-spinal fluid acetone level due to transdermal exposure to isopropanol

Dear editor, Isopropanol, also named 2-propanol or isopropyl alcohol(IPA), is a colorless, volatile liquid found in numerous household chemicals, such as cleaners and disinfectants, which typically contain a 70% solution of IPA in water. IPA is also extensively used in industry and laboratories as a solvent.

Spectrum of Neurological Disorders Related to Autoimmune Diseases in Brazzaville, Congo

Background: Autoimmune diseases, which are among the leading causes of morbidity and mortality in the world, are pathologies caused by a dysfunction of the immune system. They can affect the central nervous system, the peripheral nervous system or both nervous systems. Objectives: To describe the epidemiological, clinical, paraclinical, therapeutic and evolutive aspects of neurological disorders related to autoimmune diseases. Methods: This was a prospective cohort study. It was carried out from 1 January 2015 to 31 December 2019 (5 years). It focused on patients aged 15 years and above, who were hospitalized or followed as ambulatory patients for neurological disorders related to autoimmune diseases in the neurology department of the university teaching hospital in Brazzaville. Results: Among the 41 patients who fulfilled inclusion criteria, there were 29 (70.73%) women and 12 (29.27%) men. The average age of patients was 38.3 ± 13.8 years. An increase in the frequency of neurological disorders related to autoimmune diseases was observed every year. The main neurological disorders were neuromyelitis optica spectrum disorders (n = 14;34.15%), acute polyradiculoneuropathies (n = 13;31.71%), chronic polyradiculoneuropathies (n = 4;9.75%) and acute disseminated encephalomyelitis (n = 3;7.31%). The treatments administered, which consisted of corticosteroids and immunosuppressive drugs, had significantly improved the vital prognosis and functional status of patients (p = 0.025). Conclusion: In our study population, neurological disorders related to autoimmune diseases are rare. The neurological clinico-pathological entities diagnosed are similar to those reported in the literature. The therapeutic approaches used improve the quality of life of patients.

Is medical management useful in Moyamoya disease?

Moyamoya disease(MMD),characterized by progressive internal carotid artery stenosis and collateral vessel formation,prompts cerebral perfusion complications and is stratified into idiopathic and Moyamoya syndrome subtypes.A multifa-ceted approach toward MMD management addresses cerebral infarctions through revascularization surgery and adjunctive medical therapy,while also navigating risks such as intracranial hemorrhage and cerebral infarction resulting from arte-rial stenosis and fragile collateral vessels.Addressing antithrombotic management reveals a potential role for treatments like antiplatelet agents and anticoagulants,despite the ambiguous contribution of thrombosis to MMD-related infarctions and the critical balance between preventing ischemic events and averting hemo-rrhagic complications.Transcranial doppler has proven useful in thromboembolic detection,despite persisting challenges concerning the efficacy and safety of an-tithrombotic treatments.Furthermore,antihypertensive interventions aim to ma-nage blood pressure meticulously,especially during intracerebral hemorrhage,with recommendations and protocols varying based on the patient’s hypertension status.Additionally,lipid-lowering therapeutic strategies,particularly employing statins,are appraised for their possible beneficial role in MMD management,even as comprehensive data from disease-specific clinical trials remains elusive.Com-prehensive guidelines and protocols to navigate the multifaceted therapeutic ave-nues for MMD,while maintaining a delicate balance between efficacy and safety,warrant further meticulous research and development.This protocol manuscript seeks to elucidate the various aspects and challenges imbued in managing and navigating through the complex landscape of MMD treatment.

Retinal capillary plexus in Parkinson’s disease using optical coherence tomography angiography

AIM:To evaluate the alterations of the retinal microvasculature and foveal avascular zone in patients with Parkinson’s disease(PD)using optical coherence tomography angiography(OCT-A).METHODS:A retrospective study of PD patients examined in the Ophthalmology Department of the General Hospital of Athens,“Georgios Gennimatas”from March 2021 to March 2022 was conducted.Totally 44 patients with PD were included and 18 healthy controls were examined,hence a total of 124 eyes were enrolled in the study.The foveal and parafoveal superficial and deep capillary plexus vascular density(fSCP-VD,fDCP-VD,pSCP-VD,pDCP-CD)and foveal avascular zone(FAZ)were quantified with OCTA.Optical coherence tomography(OCT)was used to measure macular thickness.Our statistical analysis was conducted by using a mixed effect linear regression model.RESULTS:After adjustment for age and gender,the mean parafoveal superficial capillary plexus vascular density(pSCP-VD)and mean parafoveal deep capillary plexus vascular density(pDCP-VD)were significantly decreased in individuals with PD(P<0.001 in both)by-2.35(95%CI-3.3,-1.45)and-7.5(95%CI-10.4,-4.6)respectively.fSCP-VD and fDCP-VD didn’t approach statistical significance.The FAZ area and perimeter were significantly decreased(P<0.001 in both)by-0.1 mm^(2)(95%CI-0.13,-0.07)and-0.49 mm^(2)(95%CI-0.66,-0.32)respectively.Circularity didn’t approach statistical significance.Central retinal thickness(CRT)was significantly decreased in individuals with PD(P<0.001)by-23.1μm(95%CI-30.2,-16)and temporal retinal thickness(TRT)was decreased(P=0.025)by-11μm(95%CI-22,-1.5)while nasal retinal thickness(NRT)only approached statistical significance(P=0.066).CONCLUSION:The mean pSCP-VD,pDCP-VD,CRT and TRT are significantly decreased and FAZ is altered in individuals with PD.These findings can be potentially used as biomarkers for the diagnosis and evaluation of early PD.

Gp78 regulates PMP22 and causes ER stress and autophagy in EV71-VP1-overexpressing mouse Schwann cells

Background:During Enterovirus type 71(EV71)infection,the structural viral protein 1(VP1)activates endoplasmic reticulum(ER)stress associated with peripheral myelin protein 22(PMP22)accumulation and induces autophagy.However,the specific mechanism behind this process remains elusive.Methods:In this research,we used the VP1-overexpressing mouse Schwann cells(SCs)models co-transfected with a PMP22 silencing or Autocrine motility factor receptor(AMFR/gp78)overexpressing vector to explore the regulation of gp78 on PMP22 and its relationship with autophagy and apoptosis.Results:The activity of gp78 could be influenced by EV71-VP1,leading to a decrease in the ubiquitination and degradation of PMP22,resulting in PMP22 accumulation in ER.In VP1-overexpressing mouse SCs,all three ER stress sensors,including pancreatic endoplasmic reticulum kinase(PERK),activating transcription factor 6(ATF6)and inositol-requiring enzyme 1(IRE1)and the related downstream signals(C/EBP-homologous protein(CHOP)and Caspase 12)were activated,as well as the ER-resident chaperone Glucose-regulated protein 78(GRP78).In addition,VP1 upregulated the autophagy marker Microtubule-associated protein 1 light chain 3 beta(LC3B),while PMP22 silencing or gp78 overexpression reversed the phenomenon.Meanwhile,PMP22 silencing or gp78 overexpression increased proliferation of EV71-VP1-transfected mouse SCs.Conclusion:Gp78 could regulate PMP22 accumulation through ubiquitination degradation and cause ER stress and autophagy in EV71-VP1-overexpressing mouse SCs.Therefore,the gp78/PMP22/ER stress axis might emerge as a promising therapeutic target for myelin and neuronal damage induced by EV71 infection.

New insights into astrocyte diversity from the lens of transcriptional regulation and their implications for neurodegenerative disease treatments

Astrocytes are a major glial cell type in the central nervous system,and they provide trophic and metabolic support to neurons.In addition to these roles,they play crucial roles in modulating synaptic functions,development,and pruning(Brandebura et al.,2023).Astrocytes become reactive(activated)by undergoing morphological,molecular,and functional alterations in response to neuropathology such as in injuries and neurodegenerative diseases(NDs)(Escartin et al.,2021).

Short, Medium, and Long-Term Stroke Mortality in Libreville and Associated Factors

Strokes are common around the world and especially in sub-Saharan Africa. They are responsible for severe sequelae and the majority of deaths. In Gabon, no study on stroke mortality has been conducted. Objective: To determine short, medium, long-term mortality and factors associated with long-term stroke mortality. Method: Our study took place in the Neurology Department of the University Hospital Center of Libreville (UHCL). It was a historical cohort study with descriptive and analytical purposes covering the period from June 1 to August 31, 2018 and taking into account hospitalized patients from January 1, 2013 to December 31, 2017. We conducted a comprehensive systematic recruitment of patients with stroke, 18 years old and more, and had been agreed to give information. We included all patients meeting the inclusion criteria. The data was gathered using Epi-Info 7 software. The CHI-2 test was used for the comparison of frequencies and the Student’s test, for comparison of means. Multivariate analysis with logistic regression allowed us to look for factors associated with long-term mortality. A result was statistically significant for a p 0.05 value. Results: At 3 months, 28 patients (18.1%) died, at 6 months thirty-one patients or 20.1% died. At 5 years old, fifty-three patients or 34.4% had died. The factors associated with long-term mortality, if the lost of sight were all alive were tobacco (p = 0.01) and stroke (p = 0.008). If all those who were lost to sight had died, no factor was associated with 5-year mortality. Conclusion: Stroke mortality must not be taken for granted, it can be underestimated because of the large number of lost sight. Measures must be put in place to strengthen post-stroke monitoring. .

Cognitive Disorders, Depression and Anxiety in Temporal Lobe Epilepsy: An Overview

Partial epilepsies, originating in a specific brain region, affect about 60% of adults with epilepsy. Temporal lobe epilepsy (TLE) is the most prevalent subtype within this category, often necessitating surgical intervention due to its refractoriness to antiepileptic drugs (AEDs). Hippocampal sclerosis, a common underlying pathology, often exacerbates the severity by introducing cognitive and emotional challenges. This review delves deeper into the cognitive profile of TLE, along with the risk factors for cognitive disorders, depression, and anxiety in this population.

Association of DNA methylation/demethylation with the functional outcome of stroke in a hyperinflammatory state

Inflammation is closely related to stroke prognosis, and high inflammation status leads to poor functional outcome in stroke. DNA methylation is involved in the pathogenesis and prognosis of stroke. However, the effect of DNA methylation on stroke at high levels of inflammation is unclear. In this study, we constructed a hyperinflammatory cerebral ischemia mouse model and investigated the effect of hypomethylation and hypermethylation on the functional outcome. We constructed a mouse model of transient middle cerebral artery occlusion and treated the mice with lipopolysaccharide to induce a hyperinflammatory state. To investigate the effect of DNA methylation on stroke, we used small molecule inhibitors to restrain the function of key DNA methylation and demethylation enzymes. 2,3,5-Triphenyltetrazolium chloride staining, neurological function scores, neurobehavioral tests, enzyme-linked immunosorbent assay, quantitative reverse transcription PCR and western blot assay were used to evaluate the effects after stroke in mice. We assessed changes in the global methylation status by measuring DNA 5-mc and DNA 5-hmc levels in peripheral blood after the use of the inhibitor. In the group treated with the DNA methylation inhibitor, brain tissue 2,3,5-triphenyltetrazolium chloride staining showed an increase in infarct volume, which was accompanied by a decrease in neurological scores and worsening of neurobehavioral performance. The levels of inflammatory factors interleukin 6 and interleukin-1 beta in ischemic brain tissue and plasma were elevated, indicating increased inflammation. Related inflammatory pathway exploration showed significant overactivation of nuclear factor kappa B. These results suggested that inhibiting DNA methylation led to poor functional outcome in mice with high inflammation following stroke. Further, the effects were reversed by inhibition of DNA demethylation. Our findings suggest that DNA methylation regulates the inflammatory response in stroke and has an important role in the functional outcome of hyperinflammatory stroke.

Management of Spontaneous Intracerebral Haemorrhage (sICH) at the University Hospital of Brazzaville (CONGO)

Spontaneous intracerebral haemorrhage (sICH) is characterised by bleeding within the brain parenchyma, without any accompanying vascular malformation, parenchymal abnormality or coagulation disorder. The study aimed to depict the management of sICH at the University Hospital of Brazzaville (UHB). It was an observational, descriptive, and cross-sectional analysis. Data collection was conducted retrospectively, covering the period from January 1, 2020 to August 31, 2022, spanning two years and eight months. The study examined socio-demographic, diagnostic, therapeutic, and evolutionary variables. We included 274 cases. We observed 160 men (58.4%) and 114 women (41.6%), resulting in a sex ratio of 1.4. The mean age was 55.3 ± 11.4 years, with ages ranging from 31 to 93 years. The detection of sICH was typically a result of experiencing motor deficits (59.5%) or disorders of consciousness (37.2%). The weightiness of one half of the body was the most common reason for seeking medical advice. Hematoma was capsulo-lenticular in 159 cases (58%) and capsulo-thalamic in 63 cases (23%). Hematomas were <30 ml in 162 cases (59.1%) and >30 ml in 112 cases (40.9%), and associated with hydrocephalus in 11.7% of cases. Conservative medical treatment was administered in 257 cases (94.2%) while surgical treatment was performed in 16 cases (5.8%). The surgical techniques used were external ventricular drainage (EVD) in 2 cases, ventriculo-peritoneal shunt in 5 cases, and hematoma evacuation in 10 cases. Death occurred before the 7th day of hospitalisation in 73 cases (57.8%) and after in 46 cases (42.2%). The median time to death was four days (Q1 = 2 days;Q3 = 7 days), with extremes of 0 and 216 days. .

Movement analysis in the diagnosis and management of Parkinson’s disease

Challenges in the diagnosis and treatment of Parkinson’s disease:Parkinson’s disease(PD)is an increasingly prevalent neurodegenerative disease,at first sight primarily characterized by motor symptoms,although non-motor symptoms also constitute a major part of the overall phenotype.Clinically,this disease cannot be diagnosed reliably until a large part of the vulnerable dopaminergic neurons has been irretrievably lost,and the disease progresses inexorably.New biological criteria for PD have been proposed recently and might eventually improve early diagnosis,but they require further validation,and their use will initially be restricted to a research environment(Darweesh et al.,2024).

Prognosis Factors of Urinary Quality of Life in Parkinson Disease

Introduction: Quality of life in Parkinson disease is not necessary linked to motor symptoms. It’s correlated of overactive bladders and prostatic symptoms. Prognosis factors of urinary quality of life are unknown. Objectives: Our study aims to find prognosis factors of quality of life associated specifically of urinary disorders in PD. Patients and methods: We conducted a transversal, analytic and descriptive study in Physical Medicine, and Neurology departments, Fann Teaching Hospital, Dakar and included patients followed for treatment of PD. Urinary disorders, quality of life and functional autonomy were assessed respectively by Urinary Symptoms Profile (USP), Qualiven Short Form, Schwab and England Scale. Results: 38 patients presented PD, with a mean age of 60.89 ± 13.6 years and sex-ratio of 2.45. Mean duration of PD was 3.1 ± 2.9 years. Urinary disorders were found in 47.36% and dominated by incontinence (88.88%) and overactive bladders (88.88%) which were minor in more than 55%. Quality of life was impaired in 88.88% of cases. Minor forms (43.75%) were predominant and constraint dimension (50%) was the most severely altered. Prognosis factors for quality of life of urinary disorders were PD stages (0.046) and functional autonomy (0.042). Discussion and conclusion: Urinary disorders in PD are common, impaired quality of life, especially the constraint dimension, depends on stage of evolution of PD and functional autonomy of patients.

Mechanism of inflammatory response and therapeutic effects of stem cells in ischemic stroke:current evidence and future perspectives

Ischemic stroke is a leading cause of death and disability worldwide,with an increasing trend and tendency for onset at a younger age.China,in particular,bears a high burden of stroke cases.In recent years,the inflammatory response after stroke has become a research hotspot:understanding the role of inflammatory response in tissue damage and repair following ischemic stroke is an important direction for its treatment.This review summarizes several major cells involved in the inflammatory response following ischemic stroke,including microglia,neutrophils,monocytes,lymphocytes,and astrocytes.Additionally,we have also highlighted the recent progress in various treatments for ischemic stroke,particularly in the field of stem cell therapy.Overall,understanding the complex interactions between inflammation and ischemic stroke can provide valuable insights for developing treatment strategies and improving patient outcomes.Stem cell therapy may potentially become an important component of ischemic stroke treatment.

Deliberate self-harm among pediatric psychiatric inpatients in China:A single-center retrospective study

BACKGROUND For children and adolescents,deliberate self-harm(DSH)is becoming a mental health problem of concern.Despite several studies on the prevalence and factors of DSH in the world,there is little information on DSH among children and adolescents in China.This study explores the prevalence,types,associated risk factors and tendency of DSH in pediatric psychiatric inpatients in China.AIM To understand the situation of DSH among hospitalized children and adolescents and its related factors.METHODS In this study,we retrospectively studied 1414 hospitalized children and adolescents with mental illness at Xiamen Mental Health Center from 2014 to 2019,extracted the demographic and clinical data of all patients,and analyzed clinical risk factors of DSH.RESULTS A total of 239(16.90%)patients engaged in at least one type of DSH in our study.Cutting(n=115,48.12%)was the most common type of DSH.Females(n=171,71.55%)were more likely to engage in DSH than males(n=68,28.45%).DSH was positively associated with depressive disorders[OR=3.845(2.196-6.732);P<0.01],female[OR=2.536(1.815-3.542);P<0.01],parental marital status[OR=5.387(2.254-12.875);P<0.01]and negative family history of psychiatric illness[OR=7.767(2.952-20.433);P<0.01],but not with occupation,substance use and history of physical abuse.CONCLUSION Our findings suggest that for patients with depression,females,an abnormal marriage of parents,and no history of mental illness,attention should be paid to the occurrence of DSH.

Cardiovascular risk burden,dementia risk and brain structural imaging markers:a study from UK Biobank

Background Cardiovascular risk burden is associated with dementia risk and neurodegeneration-related brain structure,while the role of genetics and incident cardiovascular disease(CVD)remains unclear.Aims To examine the association of overall cardiovascular risk burden with the risk of major dementia subtypes and volumes of related brain regions in a large sample,and to explore the role of genetics and CVD onset.Methods A prospective study among 354 654 participants free of CVD and dementia(2006-2010,mean age 56.4 years)was conducted within the UK Biobank,with brain magnetic resonance imaging(MRl)measurement availablefor 15104participants since 2014.CVD risk burden was evaluated by the Framingham General Cardiovascular Risk Score(FGCRS).Dementia diagnosis was ascertained from inpatient and death register data.Results Overamedian 12.0-yearfollow-up,3998 all-cause dementia cases were identified.Higher FGCRS was associated with increasedall-cause dementia risk after adjusting for demographic,major lifestyle,clinical factors and the polygenic risk score(PRS)of Alzheimer's disease.Comparing the high versus low tertile of FGCRS,the odds ratios(ORs)and 95%confidence intervals(Cls)were 1.26(1.12 to 1.41)for all-cause dementia,1.67(1.33 to 2.09)for Alzheimer's disease and 1.53(1.07 to 2.16)for vascular dementia(all p_(treng)<0.05).Incident stroke and coronary heart disease accounted for 14%(95%Cl:9% to 21%)of the association between FGCRS and all-cause dementia.Interactions were not detected for FGCRS and PRS on the risk of any dementia subtype.We observed an 83%(95%Cl:47%to 128%)higher all-cause dementia risk comparing the high-high versus low-low FGCRS-PRS category.For brain volumes,higher FGCRS was associated with greater log-transformed white matter hyperintensities,smaller cortical volume and smaller grey matter volume.Conclusions Our findings suggest that the positive association of cardiovascular risk burden with dementia risk also applies to major dementia subtypes.The association of cardiovascular risk burden with all-cause dementia is largely independent of CVD onset and genetic predisposition to dementia.

Autoantibodies related to ataxia and other central nervous system manifestations of gluten enteropathy

Gluten ataxia and other central nervous system disorders could be linked to gluten enteropathy and related autoantibodies.In this narrative review,we focus on the various neuro-logical manifestations in patients with gluten sensitivity/celiac disease,immunological and autoimmune mechanisms of ataxia in connection to gluten sensitivity and the autoantibodies that could be used as a biomarker for diagnosing and following.We focused on the anti-gliadin antibodies,antibodies to different isoforms of tissue transglutaminase(TG)(anti-TG2,3,and 6 antibodies),anti-glycine receptor antibodies,anti-glutamine acid decarboxylase antibodies,anti-deamidated gliadin peptides antibodies,etc.Most studies found a higher prevalence of these antibodies in patients with gluten sensitivity and neurological dysfunction,presented as different neurological disorders.We also discuss the role of a gluten-free diet on the clinical improvement of patients and also on imaging of these disorders.

Fish-on-Chips:unveiling neural processing of chemicals in small animals through precise fluidic control

Precise chemical cue presentation alongside advanced brainwide imaging techniques is important to the study of chemosensory processing in animals.Nevertheless,the dynamic nature of chemical-carrying media,such as water or air,poses a significant challenge for delivering highly-controlled chemical flow to an animal subject.Moreover,contact-based cue manipulation and delivery easily shift the position of the animal subject,which is often undesirable for high-quality brain imaging.Additionally,more advanced interfacing tools that align with the diverse range of body part sizes of an animal,ranging from micrometer-scale neurons to meter-long limbs,are much needed.This is particularly crucial when dealing with dimensions that are beyond the reach of conventional experimental tools.

Voltage gated calcium channel antibody-related neurological diseases

Voltage gated calcium channel(VGCC) antibodies are generally associated with Lambert-Eaton myasthenic syndrome. However the presence of this antibody has been associated with paraneoplastic as well as nonparaneoplastic cerebellar degeneration. Most patients with VGCC-antibody-positivity have small cell lung cancer(SCLC). Lambert-Eaton myasthenic syndrome(LEMS)is an autoimmune disease of the presynaptic part of the neuromuscular junction. Its classical clinical triadis proximal muscle weakness, areflexia and autonomic dysfunction. Fifty to sixty percent of LEMS patients have a neoplasia, usually SCLC. The co-occurrence of SCLC and LEMS causes more severe and progressive disease and shorter survival than non-paraneoplastic LEMS. Treatment includes 3,4 diaminopyridine for symptomatic purposes and immunotherapy with prednisolone, azathioprine or intravenous immunoglobulin in patients unresponsive to 3,4 diaminopyridine. Paraneoplastic cerebellar degeneration(PCD) is a syndrome characterized with severe, subacute pancerebellar dysfunction. Serum is positive for VGCC antibody in 41%-44% of patients, usually with the co-occurrence of SCLC. Clinical and electrophysiological features of LEMS are also present in 20%-40% of these patients. Unfortunately, PCD symptoms do not improve with immunotherapy. The role of VGCC antibody in the immunopathogenesis of LEMS is well known whereas its role in PCD is still unclear. All patients presenting with LEMS or PCD must be investigated for SCLC.

Targeted temperature management in neurological intensive care unit

Targeted temperature management(TTM) shows the most promising neuroprotective therapy against hypoxic/ischemic encephalopathy(HIE).In addition, TTM is also useful for treatment of elevated intracranial pressure(ICP).HIE and elevated ICP are common catastrophic conditions in patients admitted in Neurologic intensive care unit(ICU).The most common cause of HIE is cardiac arrest.Randomized control trials demonstrate clinical benefits of TTM in patients with post-cardiac arrest.Although clinical benefit of ICP control by TTM in some specific critical condition, for an example in traumatic brain injury, is still controversial, efficacy of ICP control by TTM is confirmed by both in vivo and in vitro studies.Several methods of TTM have been reported in the literature.TTM can apply to various clinical conditions associated with hypoxic/ischemic brain injury and elevated ICP in Neurologic ICU.