腦外傷癲癇課件

PosttraumaticSeizure(PTS)RiskandManagementinTBI:ObjectivesGuidelinesforPTSprophylaxis:AANS,AAPMRPredictPTSriskbasedonclinicalpresentationAnalyzetreatmentstrategiesforindividualswithlatePTSfromcasestudyPosttraumaticSeizure(PTS)Ri1PosttraumaticSeizure(PTS)definitionTemporarybraindysfunctionwithexcessive,hypersynchronousdischargeofcorticalneuronsImmediate:first24hourspostinjuryEarlyPTS:first7daysLatePTS:afteroneweekPosttraumaticSeizure(PTS)de2EpilepsyRecurrentunprovokedseizuresTBIaccountsfor5-20%symptomaticepilepsyingeneralpopulationEarlyPTS->3-15%adults,10-15%children;17-33%developlatePTS,adults>childrenLatePTS->86%recurrentseizuresin2yrs(Haltineretal,2019)Epilepsy3ConsumerFeedbackearly1990’s:Anticonvulsants(AED)NoStandardofcare:AEDscontinuedindefinitelyMDsreluctanttodiscontinuemedications,especiallyprescribedbyanotherMDMemoryproblemsandcomplianceDrugsideeffects:ataxia,rashes,periodontalcare,hairgrowthorloss,slowedthinkingCostofmedications,laboratorytestsConsumerFeedbackearly1990’s4AANS(2019,2000)andAAPM&R(2019)PracticeParametersRecognizeeffectsofAEDsonrecovery,complianceLackofefficacyinpreventionoflatePTSOption:Phenytoin,carbamazepinemaypreventearlyPTSinhighriskTBI;earlyPTStreatmentdoesnotpreventlatePTSorimproveoutcomeStandard:Prophylacticanticonvulsantsnot

recommendedforpreventionoflatePTSAANS(2019,2000)andAAPM&R(205TraditionalRiskFactorsforlatePTSPenetratingshrapnelinjuries,military:53%over15years(Salazar,1985)Coma>3weeks:25%(Guidice,1987)EarlyPTS->latePTS:17-33%,agerelatedinsomestudiesIntracranialhematoma:Epidural,22%;subduralorintracerebral,45%(Jennett,1975)TraditionalRiskFactorsforl6Multi-centerstudyrationaleWhatisnaturalhistorylatePTSwithnewguidelines?CTscanfindingsnotincorporatedintoriskfactorprofileinpreviousstudiesCiviliangunshotwoundsmaybedifferentfrommilitaryshrapnelwounds->seizureriskFollow-upmechanismsalreadyinplacethroughTBIModelSystemsgrants:sufficientnumbersMulti-centerstudyrationaleWh7Hypotheses:multi-center,prospectivestudy<20%mod-severeTBI->latePTSby2years1styearincidence>2ndyearGCSinjuryseveritywillpredictlatePTSIntracraniallesionsbyCTscanpredictlatePTSDuralpenetrationpredictlatePTSHypotheses:multi-center,pros8ProspectiveenrollmentofsevereTBITraumacenters:Denver,Richmond,Detroit,SanJose>16yo,notpregnant,nopreviousseizure,stroke,tumor,intracranialsurgery;AEDs<1mopostTBICTlesionsduringfirstweekpostTBISAHorintraventricularhemorrhagecerebralcontusionepiduralorsubduralhematomadepressedskullfracturewithduralpenetrationORBestGCSinfirst24hours<10w/oCTlesionProspectiveenrollmentofseve9SeizureEvents:descriptionandchecklistsObservationinhospitalPhonefollow-upmonthlyx2yearsEventsratedbyneurologisteachcenter,blindedtoidentityofsubject.Inter-raterreliability>80%Confirmedeventscategorizedbyneurologistgeneralizedorfocal->generalizedseizurefocalseizureStatistics:survivalanalysis,relativeriskcalculationsSeizureEvents:descriptionan10Timecourseandqualityoflateposttraumaticseizures647enrolledover4years14%latePTSby2years40%occurred8-30days63%by6months80%by12months93%by18months79%generalized;21%focalTimecourseandqualityoflat11EarlyPTS(<7dayspostinjury)andlatePTS21/647(3%)hadearlyseizuresNextseizureoccurred<6monthspostinjuryRelativerisk=26%,twiceriskoftotalgroupIfprophylaxisconsideredforthisgroup,noneedtotreat>6monthsifearlyPTSEarlyPTS(<7dayspostinjury12InitialGCSandlatePTSGCS3-8:17%relativeriskGCS9-12:24%relativeriskGCS13-15:8%relativeriskSeverityofinjuryasmeasuredbyGCSdidnotcorrelatewithlatePTSGCSnotparticularlyhelpfulinpredictingseizureriskInitialGCSandlatePTSGCS3-13MidlineshiftandcisternalcompressiononCTscanandlatePTSCisternsopen,<1mmshift:10%Cisternsopen,1-5mmshift:15%Cisternscompressed,<5mmshift:18%>5mmshift:26%DegreeofcerebralcompressionisassociatedwithlatePTS,especially>5mmmidlineshiftMidlineshiftandcisternalco14CorticalContusions:RelativeriskoflatePTSNocontusion:6%Singlecontusion:8%Bilateralormultiplecontusions:25%bifrontal:26%bitemporal:31%biparietal:66%BilateralcontusionsamongsthighestriskfactorsforlatePTSCorticalContusions:Relative15SubcorticalcontusionsandrelativeriskforlatePTSNosubcorticalcontusion:13%Singlesubcorticalcontusion:16%Multiplesubcorticalcontusions:33%HighassociationofmultiplesubcorticalcontusionsandlatePTS:probablymarkerforsevereTBI.Subcorticalcontusionsandrel16PenetratingInjuriesandlatePTSNopenetratingbone,metalfragments:14%Bonefragmentsonly:0%Boneandmetalfragments:63%Metalfragments(bullets)haveaveryhighassociationwithlatePTSandarecomparabletoshrapnelinjuries.Bonefragmentsalonehaveminimalincreasedrisk.PenetratingInjuriesandlate17MasslesionsandrelativeriskoflatePTSEpiduralhematoma(EDH)noEDH:14%EDH,noevacuation:8%EDHwithevacuation:19%Subduralhematoma(SDH)noSDH:10%SDH,noevacuation:15%SDHwithevacuation:28%Masslesionsandrelativerisk18NeurosurgicalproceduresandrelativeriskoflatePTS>1evacuationofintracerebralhematoma:75%>1operation:37%;1operation:15%;none:11%Ventriculostomy:25%;noventriculostomy:13%Moresevereinjuriesrequiremoreneurosurgicalprocedures;thoseindividualshave

higherriskoflatePTSNeurosurgicalproceduresandr19LengthofphenytoinprophylaxisandrelativeriskoflatePTSDaysDPH %RelativeriskNone 7%1-7 days 12%8-14days 17%15-30days 30%**p=.0002ProbablyamarkerformoresevereinjuryLengthofphenytoinprophylaxi20StudyLimitationsDuralpenetration“n”toosmall(26/647)Prolongedorlateanticonvulsantuse:sickerpatientshadtobedroppedSelfreportofsymptoms:biastoseizuresthatgeneralizeasthesearemorerecognizableConcomitantfactors:midlineshiftisoftenacriteriaforsurgery,sowhichisthepredominantriskfactor?StudyLimitations21ConclusionsAANSandAAPMRguidelinesaresupportedMostPTSoccurin18mospostTBIGCSseverityinsufficienttopredictPTSriskConclusionsAANSandAAPMRguid22ConclusionsVeryhighriskgroups:earlyPTS,multiplecontusions,midlineshift>5mm,subduralhematomasurgery,multipleoperations,boneandmetalfragmentsIstherearoleforprophylaxisinveryhighriskgroups?Doubleblindrandomizedstudy,moreinstitutionsQualityoflife,RTW/school,independentlivinginindividualswithPTSvnone:needsstudyConclusionsVeryhighriskgrou23RTcasestudyslide120yomanwithGSWtolefttemporaloccipitalareasRcavernouscarotidfistula->balloonocclusionLatePTSwhendevelopedseverehydrocephalusVentriculoperitonealshunt10weekspostinjuryAcuterehab13weekspostinjury,Rancho3-4valproateforseizureandpantoprazoleforGIprotection;cuffedtracheostomy Communicateswitheyeblinks,fingermovements CrN2,3,6,7,9,10,12injuries RUEsomeselectivemovement;tremorandsynergyinLUE,bilateralLEWhatishisriskfactorprofile?Continuetotreat?RTcasestudyslide120yoman24RTcasestudyslide2Withconsentfrombrothervalproateistaperedtodecreasetremor;everyonewatchingforseizuresYoudeflatehistrachandwithin2dayschangetocufflessFoleytocondomcatheter,continuoustobolusfeedingCogwheelrigidityandtremorwithmovement,noseizuresHowdoyoutreathiscogwheelrigidityandtremor?RTcasestudyslide2Withcons25RTcasestudyslide3SinemetstartedusingADLandwheelchairmobilityasperformanceparameters41/2monthspostinjury,30secondLOC,LEshakinganddifficultybreathing.ResumedpreviousleveloffunctioningwithinhoursWhatisthisepisode?Whatdiagnosticinterventionsareappropriate?RTcasestudyslide3Sinemets26RTcasestudyslide4ComplexpartialseizurewithrespiratorydistressNoevidenceofinfectioninlungs,urineElectrolytes(Na,Ca,Mg,CO2,BUN/Cr)normalCTscanshowedcontinuedimprovementinhydrocephalus,subduralfluidcollectionsUnprovokedseizure,associatedwithveryhighincidenceofrecurrentepisodesWhatmedicationwouldcausetheleasttoxicity?RTcasestudyslide4Complexp27RTcasestudyslide5Lamotriginepickedbecauselowsedationpotential,lowincidenceofmotorsideeffectsGradualbuild-upofdoseOK,givenrapidrecoveryfromthisseizureeventOthermedicationconsiderationsValproate,phenytoin,carbamazepine:motoricsideeffectslevetiracetam:renalclearance,notsedatingoxcarbazepine:lessmotortoxicitythancarbamazepineRTcasestudyslide5Lamotrigi28DKcasestudyslide126yoLHfemale,motorcyclecrashwhilehelmetedEMSGCS6,eyesdeviatedtoleft,bloodyvomitusinmouth,tonic-clonicmovementsinextremitiesCTscan:Rmaxillarysinusfracture,nocontusionsSocial:streetdrugarrests;sober,working2yearsWhatisthisepisode?Howshouldshebetreated?DKcasestudyslide126yoLH29DKcasestudyslide2ImmediatePTSIntubatedinER;ICPmonitorshowed38mmHgICPcontrolledwithventilation,mannitolPhenytoinstartedIVFollow-upCTscan:bifrontalcontusions,LsubduralhygromaTracheostomyperformedafterfailedweaningAgitationmanagedwithlorazepamHowlongshouldshebetreatedwithAEDs?SDKcasestudyslide2Immediate30DKcasestudyslide33weekspostinjury,admissiontoacuterehabilitationtracheostomy,NGtubewithcontinuousfeedings,nonfluentaphasia,Lhemiparesis,LVFdefect,Rancho3-4,maxassistancemobilityandADLs.Meds:phenytoin,prnlorazepam,pepcidHowwouldyoumanageherrehabilitationandhermedicationsDKcasestudyslide33weeksp31DKcasestudyslide4Regulatescheduleformobility,ADL,bolusfeeding,communicationstrategies,netbed,weantrach DCphenytoin,pepcid.Taperbenzodiazepinestoimprovelevelofalertness.Noindication.PTAresolves6weeks;safetyawarenessimproves7weekspostTBI,episodeofunresponsiveness,headandeyedeviationtoleftfor<60secondsduringfamilyvisit.Whatisthisepisode?Whatwouldyoudo?DKcasestudyslide4Regulate32DKcasestudyslide5Complexpartialseizure.Electrolytes,CBCallnormal,CTnotdoneHowshouldyouandpatientdecidetotreat?DKcasestudyslide5Complexp33DKCasestudyslide6Medicationshavesideeffects:weightgain,facialhair,alopecia,bloodtests,slowedthinkingLikelihoodofrecurrentseizureis>80%Drivingnotimmediateissue:VFdeficitSupportreasonablechoicebypatient,familyShedecidestotakeachancewithoutmedicationDKCasestudyslide6Medicatio34ConsiderationsofantiepilepticdrugchoiceCompliance:once/dayvs.multipledosesphenytoin,phenobarbitalonce/dayallothersare2-3times/dayDesiredsideeffects:moodstabilization,neuropathicpainUndesiredsideeffects:sedation,interactions,cognitiveslowing,weightgain,bloodmonitoring,hairandgingivalgrowthConsiderationsofantiepilepti35BibliographyBrainInjurySpecialInterestGroupoftheAmericanAcademyofPhysicalMedicineandRehabilitation,Practiceparameter:antiepilepticdrugtreatmentofposttraumaticseizures.ArchPhysMedRehabil2019;79;594-597BrainTraumaFoundation,AmericanAssociationofNeurologicalSurgeons,TheroleofantiseizureprophylaxisfollowingheadinjuryinGuidelinesforthemanagementofseveretraumaticbraininjury.ISBN0-9703144-0-X:159-165EnglanderJ,BushnikT,DuongTT,CifuDX,etal,Analyzingriskfactorsforlateposttraumaticseizures:aprospective,multi-centerinvestigation.ArchPhysMedRehabil2019;84:365-373JennetB,Epilepsyafternon-missileheadinjuries,ed2.Chicago:WilliamHeinemann,1975HaltinerAM,TemkinNR,DickmenSS,RiskofseizurerecurrenceafterthefirstPTS.ArchPhysMedRehabil2019;78;835-840.SalazarAMetal,Epilepsyafterpenetratingheadinjury:1.Clinicalcorrelates.Neurology1985;35:1406-1414.YablonS,Posttraumaticseizures.ArchPhysMedRehabil1993;74;983-1001BibliographyBrainInjurySpeci36謝謝謝謝37腦外傷癲癇課件38PosttraumaticSeizure(PTS)RiskandManagementinTBI:ObjectivesGuidelinesforPTSprophylaxis:AANS,AAPMRPredictPTSriskbasedonclinicalpresentationAnalyzetreatmentstrategiesforindividualswithlatePTSfromcasestudyPosttraumaticSeizure(PTS)Ri39PosttraumaticSeizure(PTS)definitionTemporarybraindysfunctionwithexcessive,hypersynchronousdischargeofcorticalneuronsImmediate:first24hourspostinjuryEarlyPTS:first7daysLatePTS:afteroneweekPosttraumaticSeizure(PTS)de40EpilepsyRecurrentunprovokedseizuresTBIaccountsfor5-20%symptomaticepilepsyingeneralpopulationEarlyPTS->3-15%adults,10-15%children;17-33%developlatePTS,adults>childrenLatePTS->86%recurrentseizuresin2yrs(Haltineretal,2019)Epilepsy41ConsumerFeedbackearly1990’s:Anticonvulsants(AED)NoStandardofcare:AEDscontinuedindefinitelyMDsreluctanttodiscontinuemedications,especiallyprescribedbyanotherMDMemoryproblemsandcomplianceDrugsideeffects:ataxia,rashes,periodontalcare,hairgrowthorloss,slowedthinkingCostofmedications,laboratorytestsConsumerFeedbackearly1990’s42AANS(2019,2000)andAAPM&R(2019)PracticeParametersRecognizeeffectsofAEDsonrecovery,complianceLackofefficacyinpreventionoflatePTSOption:Phenytoin,carbamazepinemaypreventearlyPTSinhighriskTBI;earlyPTStreatmentdoesnotpreventlatePTSorimproveoutcomeStandard:Prophylacticanticonvulsantsnot

recommendedforpreventionoflatePTSAANS(2019,2000)andAAPM&R(2043TraditionalRiskFactorsforlatePTSPenetratingshrapnelinjuries,military:53%over15years(Salazar,1985)Coma>3weeks:25%(Guidice,1987)EarlyPTS->latePTS:17-33%,agerelatedinsomestudiesIntracranialhematoma:Epidural,22%;subduralorintracerebral,45%(Jennett,1975)TraditionalRiskFactorsforl44Multi-centerstudyrationaleWhatisnaturalhistorylatePTSwithnewguidelines?CTscanfindingsnotincorporatedintoriskfactorprofileinpreviousstudiesCiviliangunshotwoundsmaybedifferentfrommilitaryshrapnelwounds->seizureriskFollow-upmechanismsalreadyinplacethroughTBIModelSystemsgrants:sufficientnumbersMulti-centerstudyrationaleWh45Hypotheses:multi-center,prospectivestudy<20%mod-severeTBI->latePTSby2years1styearincidence>2ndyearGCSinjuryseveritywillpredictlatePTSIntracraniallesionsbyCTscanpredictlatePTSDuralpenetrationpredictlatePTSHypotheses:multi-center,pros46ProspectiveenrollmentofsevereTBITraumacenters:Denver,Richmond,Detroit,SanJose>16yo,notpregnant,nopreviousseizure,stroke,tumor,intracranialsurgery;AEDs<1mopostTBICTlesionsduringfirstweekpostTBISAHorintraventricularhemorrhagecerebralcontusionepiduralorsubduralhematomadepressedskullfracturewithduralpenetrationORBestGCSinfirst24hours<10w/oCTlesionProspectiveenrollmentofseve47SeizureEvents:descriptionandchecklistsObservationinhospitalPhonefollow-upmonthlyx2yearsEventsratedbyneurologisteachcenter,blindedtoidentityofsubject.Inter-raterreliability>80%Confirmedeventscategorizedbyneurologistgeneralizedorfocal->generalizedseizurefocalseizureStatistics:survivalanalysis,relativeriskcalculationsSeizureEvents:descriptionan48Timecourseandqualityoflateposttraumaticseizures647enrolledover4years14%latePTSby2years40%occurred8-30days63%by6months80%by12months93%by18months79%generalized;21%focalTimecourseandqualityoflat49EarlyPTS(<7dayspostinjury)andlatePTS21/647(3%)hadearlyseizuresNextseizureoccurred<6monthspostinjuryRelativerisk=26%,twiceriskoftotalgroupIfprophylaxisconsideredforthisgroup,noneedtotreat>6monthsifearlyPTSEarlyPTS(<7dayspostinjury50InitialGCSandlatePTSGCS3-8:17%relativeriskGCS9-12:24%relativeriskGCS13-15:8%relativeriskSeverityofinjuryasmeasuredbyGCSdidnotcorrelatewithlatePTSGCSnotparticularlyhelpfulinpredictingseizureriskInitialGCSandlatePTSGCS3-51MidlineshiftandcisternalcompressiononCTscanandlatePTSCisternsopen,<1mmshift:10%Cisternsopen,1-5mmshift:15%Cisternscompressed,<5mmshift:18%>5mmshift:26%DegreeofcerebralcompressionisassociatedwithlatePTS,especially>5mmmidlineshiftMidlineshiftandcisternalco52CorticalContusions:RelativeriskoflatePTSNocontusion:6%Singlecontusion:8%Bilateralormultiplecontusions:25%bifrontal:26%bitemporal:31%biparietal:66%BilateralcontusionsamongsthighestriskfactorsforlatePTSCorticalContusions:Relative53SubcorticalcontusionsandrelativeriskforlatePTSNosubcorticalcontusion:13%Singlesubcorticalcontusion:16%Multiplesubcorticalcontusions:33%HighassociationofmultiplesubcorticalcontusionsandlatePTS:probablymarkerforsevereTBI.Subcorticalcontusionsandrel54PenetratingInjuriesandlatePTSNopenetratingbone,metalfragments:14%Bonefragmentsonly:0%Boneandmetalfragments:63%Metalfragments(bullets)haveaveryhighassociationwithlatePTSandarecomparabletoshrapnelinjuries.Bonefragmentsalonehaveminimalincreasedrisk.PenetratingInjuriesandlate55MasslesionsandrelativeriskoflatePTSEpiduralhematoma(EDH)noEDH:14%EDH,noevacuation:8%EDHwithevacuation:19%Subduralhematoma(SDH)noSDH:10%SDH,noevacuation:15%SDHwithevacuation:28%Masslesionsandrelativerisk56NeurosurgicalproceduresandrelativeriskoflatePTS>1evacuationofintracerebralhematoma:75%>1operation:37%;1operation:15%;none:11%Ventriculostomy:25%;noventriculostomy:13%Moresevereinjuriesrequiremoreneurosurgicalprocedures;thoseindividualshave

higherriskoflatePTSNeurosurgicalproceduresandr57LengthofphenytoinprophylaxisandrelativeriskoflatePTSDaysDPH %RelativeriskNone 7%1-7 days 12%8-14days 17%15-30days 30%**p=.0002ProbablyamarkerformoresevereinjuryLengthofphenytoinprophylaxi58StudyLimitationsDuralpenetration“n”toosmall(26/647)Prolongedorlateanticonvulsantuse:sickerpatientshadtobedroppedSelfreportofsymptoms:biastoseizuresthatgeneralizeasthesearemorerecognizableConcomitantfactors:midlineshiftisoftenacriteriaforsurgery,sowhichisthepredominantriskfactor?StudyLimitations59ConclusionsAANSandAAPMRguidelinesaresupportedMostPTSoccurin18mospostTBIGCSseverityinsufficienttopredictPTSriskConclusionsAANSandAAPMRguid60ConclusionsVeryhighriskgroups:earlyPTS,multiplecontusions,midlineshift>5mm,subduralhematomasurgery,multipleoperations,boneandmetalfragmentsIstherearoleforprophylaxisinveryhighriskgroups?Doubleblindrandomizedstudy,moreinstitutionsQualityoflife,RTW/school,independentlivinginindividualswithPTSvnone:needsstudyConclusionsVeryhighriskgrou61RTcasestudyslide120yomanwithGSWtolefttemporaloccipitalareasRcavernouscarotidfistula->balloonocclusionLatePTSwhendevelopedseverehydrocephalusVentriculoperitonealshunt10weekspostinjuryAcuterehab13weekspostinjury,Rancho3-4valproateforseizureandpantoprazoleforGIprotection;cuffedtracheostomy Communicateswitheyeblinks,fingermovements CrN2,3,6,7,9,10,12injuries RUEsomeselectivemovement;tremorandsynergyinLUE,bilateralLEWhatishisriskfactorprofile?Continuetotreat?RTcasestudyslide120yoman62RTcasestudyslide2Withconsentfrombrothervalproateistaperedtodecreasetremor;everyonewatchingforseizuresYoudeflatehistrachandwithin2dayschangetocufflessFoleytocondomcatheter,continuoustobolusfeedingCogwheelrigidityandtremorwithmovement,noseizuresHowdoyoutreathiscogwheelrigidityandtremor?RTcasestudyslide2Withcons63RTcasestudyslide3SinemetstartedusingADLandwheelchairmobilityasperformanceparameters41/2monthspostinjury,30secondLOC,LEshakinganddifficultybreathing.ResumedpreviousleveloffunctioningwithinhoursWhatisthisepisode?Whatdiagnosticinterventionsareappropriate?RTcasestudyslide3Sinemets64RTcasestudyslide4ComplexpartialseizurewithrespiratorydistressNoevidenceofinfectioninlungs,urineElectrolytes(Na,Ca,Mg,CO2,BUN/Cr)normalCTscanshowedcontinuedimprovementinhydrocephalus,subduralfluidcollectionsUnprovokedseizure,associatedwithveryhighincidenceofrecurrentepisodesWhatmedicationwouldcausetheleasttoxicity?RTcasestudyslide4Complexp65RTcasestudyslide5Lamotriginepickedbecauselowsedationpotential,lowincidenceofmotorsideeffectsGradualbuild-upofdoseOK,givenrapidrecoveryfromthisseizureeventOthermedicationconsiderationsValproate,phenytoin,carbamazepine:motoricsideeffectslevetiracetam:renalclearance,notsedatingoxcarbazepine:lessmotortoxicitythancarbamazepineRTcasestudyslide5Lamotrigi66DKcasestudyslide126yoLHfemale,motorcyclecrashwhilehelmetedEMSGCS6,eyesdeviatedtoleft,bloodyvomitusinmouth,tonic-clonicmovementsinextremitiesCTscan:Rmaxillarysinusfracture,nocontusionsSocial:streetdrugarrests;sober,working2yearsWhatisthisepisode?Howshouldshebetreated?DKcasestudyslide126yoLH67DKcasestudyslide2ImmediatePTSIntubatedinER;ICPmonitorshowed38mmHgICPcontrolledwithventilation,mannitolPhenytoinstartedIVFollow-upCTscan:bifrontalcontusions,LsubduralhygromaTracheostomyperformedafterfailedweaningAgitationmanagedwithlorazepamHowlongshouldshebetreatedwithAEDs?SDKcasestudyslide2Immediate68DKcasestudyslide33weekspostinjury,admissiontoacuterehabilitationtracheostomy,NGtubewithcontinuousfeedings,nonfluentaphasia,Lhemiparesis,LVFdefect,Rancho3-4,maxassistancemobilityandADLs.Meds:p