Treatment of idiopathic intracranial hypertension with gastric bypass surgery.

Idiopathic intracranial hypertension (IIH) is defined by elevated intracranial pressure and associated headaches, changes in vision and pulsatile tinnitus, among other symptoms. It occurs most frequently in young, obese women. Gastric bypass surgery has been used to treat morbid obesity and its comorbidities, and IIH has recently been considered among these indications. We present a case report of a 29-year-old female with a maximum BMI of 50.3 and a 5-year history of severe headaches and moderate papilledema due to IIH. She also developed migraine headaches. After a waxing and waning course and various medical treatments, the patient underwent laparoscopic Roux-en-Y gastric bypass surgery with anterior repair of hiatal hernia. Dramatic improvement in IIH headaches occurred by 4 months postprocedure and was maintained at 1 year, when she reached her weight plateau with a BMI of 35. Presurgery migraines persisted. This adds to the small number of case reports and retrospective analyses of the successful treatment of IIH with gastric bypass surgery, and brings this data from the surgical literature into the neurological domain. It offers insight into an early time course for symptom resolution, and explores the impact of weight-loss surgery on migraine headaches. This treatment modality should be further investigated prospectively to analyze the rate of headache improvement with weight loss, the amount of weight loss needed for clinical improvement, and the possible correlation with improvement in papilledema.

Management of orthostatic hypotension in patients with Parkinson's disease.

Orthostatic hypotension is common in Parkinson's disease. The current recommended management of orthostatic hypotension related to Parkinson's disease involves first general measures and then medications with little risk of severe adverse side effects.

Differences in motor and cognitive function in patients with Parkinson's disease with and without orthostatic hypotension.

Patients with Parkinson's disease (PD) often present with orthostatic hypotension (OH) as a result of the dysautonomia associated with the disease or as a side effect of the dopaminergic medications used to treat the disease. The purpose of this study was to investigate differences in motor and cognitive function in patients with PD with and without OH. Forty-four patients with a diagnosis of PD were evaluated and stratified by the presence of OH based on orthostatic blood pressure recordings. Both groups underwent assessments of motor and cognitive function. OH was present in 17 of 44 patients (39%) with PD. These patients with OH had significantly lower scores in gross motor, balance, and cognitive function (p < .05). No significant difference between groups was found in the finger tapping scores. These results suggest that patients with PD should be routinely screened for OH as it commonly occurs and may negatively impact gross motor, balance, and cognitive function.

Bilateral Paragangliomas in the Setting of Autonomic Dysfunction: A Case Report.

In 2018, a 59-year-old female patient presented with hoarseness in her voice, headache, intermittent pain in her right side, difficulty of right arm movement, left side neck pain, difficulty controlling hypertension of unknown etiology, and a large mass on the upper left side of her neck with a smaller mass on the right side. MRI of the neck revealed masses at each carotid bifurcation. These were determined to be bilateral paragangliomas. Paragangliomas are rare tumors, and bilateral ones tremendously so. The patient underwent radiation over 2 years, resulting in the successful shrinking and stabilization of both masses. Since completing radiation, the patient reported improvement in her memory, and her blood pressure has stabilized with medication.

Acute occlusion of the fetal posterior cerebral artery: diagnosis and management paradigms.

BACKGROUND AND PURPOSE: The diagnosis and management of acute fetal posterior cerebral artery occlusion are challenging. While endovascular treatment is established for anterior circulation large vessel occlusion stroke, little is known about the course of acute fetal posterior cerebral artery occlusions. We report the clinical course, radiological findings and management considerations of acute fetal posterior cerebral artery occlusion stroke. METHODS: We performed a retrospective review of consecutive patients presenting with acute large vessel occlusion who underwent cerebral angiogram and/or mechanical thrombectomy between January 2015 and January 2021. Patients diagnosed with fetal posterior cerebral artery occlusion were included. Demographic data, clinical presentation, imaging findings and management strategies were reviewed. RESULTS: Between January 2015 and January 2021, three patients with fetal posterior cerebral artery occlusion were identified from 400 patients who underwent angiogram and/or mechanical thrombectomy for acute stroke (0.75%). The first patient presented with concomitant fetal posterior cerebral artery and middle cerebral artery occlusions. Thrombectomy was performed with recanalisation of the fetal posterior cerebral artery but the patient died from malignant oedema. The second patient presented with isolated fetal posterior cerebral artery occlusion. No endovascular intervention was performed and the patient was disabled from malignant posterior cerebral artery infarct. The third patient presented with carotid occlusion and was found to have fetal posterior cerebral artery occlusion after internal carotid artery recanalisation. No further intervention was performed. The patient was left with residual contralateral homonymous hemianopia and mild left sided weakness. CONCLUSION: Fetal posterior cerebral artery occlusion is a rare, but potentially disabling, cause of ischaemic stroke. Endovascular treatment is feasible. Further investigation is needed to compare the efficacy of medical versus endovascular management strategies.

Dry Eye Syndrome and Sicca Complex are Commonly Found in Patients with Postural Orthostatic Tachycardia Syndrome.

PURPOSE: Patients with postural orthostatic tachycardia syndrome (POTS) present to outpatient dysautonomia clinics endorsing a wide range of symptoms. Dry eyes and mouth, or sicca complex are frequently reported. This retrospective study investigates the incidence and quantifies the severity of dry eye syndrome (DES) in patients with POTS. PATIENTS AND METHODS: This retrospective study compiles survey results, and dry eye clinical data from twenty-three POTS patients (22 females, average age 34.9 and st dev 14.0 years) surveyed during their initial or follow-up appointments. Patient's medication lists were documented to account for anticholinergics, antihistamines, and anticholinesterase use. Patients endorsing dry eye symptoms were tested with Schirmer's test strips to identify clinically dry eyes and stratified for severity. RESULTS: Sixty-five percent of patients endorsed dry eye symptoms (15/23). Seventy-four percent of patients endorsed dry mouth symptoms (17/23). Among patients endorsing dry eyes, 81% of eyes had decreased tear production with Schirmer's strip wetting less than 10 mm/5 min (13/16). CONCLUSION: DES is an additional and significant disease burden for the POTS patient population. Dry eye and exocrine gland function should be evaluated as part of the dysautonomia work up with referral to ophthalmology as appropriate. Patients with clinically dry eyes who report additional autonomic dysfunction should be further evaluated for widespread autonomic dysfunction.

Neurology Residents as Comprehensive Educators (Neuro RACE).

Residents are expected to be educators often without any formal schooling, and many continue a career in academic medicine where they play a pivotal role in education. However, few resident curricula have been published to include instruction in teaching, particularly in the field of Neurology. To guide Neurology residents as they take on their role as a clinician-educator, we developed a 1-year curriculum (Neurology Residents as Comprehensive Educators "Neuro RACE") with monthly sessions divided into didactics, small group discussions, and interactive kinetic learning. A postcurriculum survey was used to evaluate the residents' response to this curriculum. Residents reported an overall improvement in their comfort and confidence in their teaching abilities. As an integral part of academic training, residents-as-teachers curricula should take a prominent role in Neurology training programs.

Safety Considerations During Transitions of Care From Inpatient to Outpatient Settings.

Hospital admissions are times of intense change. New medications are started, treatment regimens are modified, and care plans that will continue in the outpatient setting are initiated. After discharge, most patients receive care from different providers than those seen in the hospital. This situation will increase as inpatient-based practice patterns, such as neurohospitalist practices, become more prevalent. Communication failures during the transition from hospital to clinic increase the risk of adverse events. Providers must realize that successful transition can impact the patient's health as significantly as treatment of the admitting diagnosis. The transition should be carefully planned and standardized. This article discusses common pitfalls encountered during the transition period and highlights methods to improve patient care and safety.

Cultural Barriers to Medication Adherence in Epilepsy.

Antiepileptic drugs can prevent seizures in most patients; however, nonadherence is frequently reported. Nonadherence is associated with a higher incidence of emergency department visits, increased hospital admissions, and an increased risk of mortality. Misconceptions about epilepsy, level of education, and language barriers are contributors to nonadherence. Misconceptions about epilepsy and antiepileptic drugs are prevalent among economically disadvantaged predominantly minority persons with epilepsy. Educational interventions may improve adherence.

Comprehensive Opportunities for Research and Teaching Experience (CORTEX): A mentorship program.

OBJECTIVE: We developed a program to promote medical student interest in pursuing a career in neurology. This program focuses on medical student mentorship. It also offers opportunities in teaching and clinical research in order to provide students with marketable skills for an academic career in neurology. METHODS: Through this program, students are provided with guidance in developing a fourth-year clerkship schedule and an application package for residency programs. Students are involved and mentored in clinical research. Opportunities are also provided for students to teach their peers, with sessions focusing on examination preparation. RESULTS: Since the implementation of this program in 2010, the number of students entering into the field of neurology from our institution significantly increased from 14 students between 2006 and 2010, to 30 students between 2011 and 2014 (p < 0.05). Medical student research productivity increased from 7 publications during 2006-2010, to 22 publications, 14 poster presentations, and a book chapter after implementation of this program in 2010 (p < 0.05). CONCLUSIONS: In this mentoring program, students are prepared for residency application and provided with research and teaching opportunities. Students develop a highly desirable academic skill set for residency and have matched at top-ranked institutions. This program has been successful in improving student productivity in clinical research and garnering student interest in neurology.

Two patients with Hashimoto's encephalopathy and uncontrolled diabetes successfully treated with levetiracetam.

Hashimoto's encephalopathy (HE) is a rare syndrome of progressive or relapsing-remitting encephalopathy associated with elevated serum anti-thyroid antibody concentrations. It is thought to be an autoimmune process that generally responds well to high-dose corticosteroids and other immunomodulatory therapies. However, some patients are unresponsive to steroids or are unable to receive immune therapy. A viable alternative is needed for this group. Given that seizure and EEG abnormalities are commonly associated with this syndrome, we postulate that treatment with levetiracetam, which has duel anti-inflammatory and anti-seizure mechanisms, might show clinical benefit. We present the cases of two patients who met the criteria for HE but were unable to receive steroids due to labile diabetes. They were both successfully treated with levetiracetam.

Levetiracetam as a possible contributor to acute kidney injury.

PURPOSE: Levetiracetam is an antiepileptic medication that has been reported to be both well-tolerated and effective in treating generalized tonic-clonic, myoclonic, and partial-onset seizures. The adverse effects most commonly reported in tolerability trials include somnolence, fatigue/asthenia, headaches, dizziness, and nausea. However, there have been a few reports suggesting possible detrimental effects of levetiracetam on renal function. METHODS: Here we describe the case of a previously healthy 23-year-old female patient who developed acute kidney injury 1 day after the initiation of levetiracetam therapy for new-onset seizures. FINDINGS: Based on the time course of the patient's rise in serum creatinine and the exclusion of other causes, this case suggests that levetiracetam use contributed to the acute kidney injury. IMPLICATIONS: Levetiracetam is a widely used drug that has been reported to be generally tolerable and effective; however, it has the potential to negatively affect renal function. This potential consequence of therapy should be considered when deciding whether or not to prescribe this medication, and renal function should be monitored during treatment.

Neurologists and technology: The changing "Facebook" of practice.

Social and traditional media are revolutionizing health care. Medicine, once an art practiced behind closed doors, is now part of the public domain. This article will help neurologists navigate a complex maze of technology to optimize patient care without compromising privacy. We offer ideas for improving our digital "footprint." Guidance is given on maintaining professional demeanor in all private and public interactions to help us avoid personal or patient insult and injury. Acknowledging that neurology is becoming a specialty of increased personal and social education, we outline ways to proactively improve our patient care and education locally and globally.

Effectiveness of an inpatient movement disorders program for patients with atypical parkinsonism.

This paper investigated the effectiveness of an inpatient movement disorders program for patients with atypical parkinsonism, who typically respond poorly to pharmacologic intervention and are challenging to rehabilitate as outpatients. Ninety-one patients with atypical parkinsonism participated in an inpatient movement disorders program. Patients received physical, occupational, and speech therapy for 3 hours/day, 5 to 7 days/week, and pharmacologic adjustments based on daily observation and data. Differences between admission and discharge scores were analyzed for the functional independence measure (FIM), timed up and go test (TUG), two-minute walk test (TMW), Berg balance scale (BBS) and finger tapping test (FT), and all showed significant improvement on discharge (P > .001). Clinically significant improvements in total FIM score were evident in 74% of the patients. Results were similar for ten patients whose medications were not adjusted. Patients with atypical parkinsonism benefit from an inpatient interdisciplinary movement disorders program to improve functional status.

Treating orthostatic hypotension in patients with Parkinson's disease and atypical Parkinsonism improves function.

BACKGROUND: Patients with idiopathic Parkinson's disease (PD) or atypical Parkinsonism (AP) often present with orthostatic hypotension (OH) as a result of the dysautonomia associated with the disease or as a side effect of the dopaminergic medications used to treat it. Our recent study suggested that OH negatively impacts gross motor, balance, and cognitive functions in patients with PD. OBJECTIVE: To determine if correcting the orthostatic hypotension (OH) of patients with PD or AP improves their gross motor, balance, and cognitive functions. METHODS: Forty patients with PD or AP were assessed before and after correcting their OH using a staged approach with a goal of SBP >80 when standing and SBP <180 when laying. Step 1 of treatment included reducing antihypertensive medications, as possible, maintaining hydration with 1500cc/day, decreasing dietary salt, wearing high compression stockings, and keeping the head of bed elevated at 30 degrees when supine. If SBP <80 with standing after step 1, then treatment was started with fludrocortisone and/or midodrine. RESULTS: Patients' OH was managed as part of a rehabilitation program. Tests such as the Motor and Cognitive Functional Independence Measures, Berg Balance Scale, Two Minute Walking test, and the Finger Tapping test showed significant improvements (p < 0.05) in their gross motor, walking, balance and cognitive function with our OH management plan. No significant differences between admission and discharge were found in the Timed Up and Go test. CONCLUSION: Our data suggest that monitoring and correcting the OH of patients with PD or AP improves their gross motor, balance, and cognitive function.