Antiseizure Medication Use and Outcomes After Suspected or Confirmed Acute Symptomatic Seizures.

Importance: Antiseizure medications (ASMs) are frequently prescribed for acute symptomatic seizures and epileptiform abnormalities (EAs; eg, periodic or rhythmic patterns). There are limited data on factors associated with ASM use and their association with outcomes. Objectives: To determine factors associated with ASM use in patients with confirmed or suspected acute symptomatic seizures undergoing continuous electroencephalography, and to explore the association of ASMs with outcomes. Design, Setting, and Participants: This multicenter cohort study was performed between July 1 and September 30, 2021, at 5 US centers of the Post Acute Symptomatic Seizure Investigation and Outcomes Network. After screening 1717 patients, the study included 1172 hospitalized adults without epilepsy who underwent continuous electroencephalography after witnessed or suspected acute symptomatic seizures. Data analysis was performed from November 14, 2023, to February 2, 2024. Exposure: ASM treatment (inpatient ASM continuation ≥48 hours). Main Outcomes and Measures: Factors associated with (1) ASM treatment, (2) discharge ASM prescription, and (3) discharge and 3-month Glasgow Outcome Scale score of 4 or 5 were ascertained. Results: A total of 1172 patients (median [IQR] age, 64 [52-75] years; 528 [45%] female) were included. Among them, 285 (24%) had clinical acute symptomatic seizures, 107 (9%) had electrographic seizures, and 364 (31%) had EAs; 532 (45%) received ASM treatment. Among 922 patients alive at discharge, 288 (31%) were prescribed ASMs. The respective frequencies of inpatient ASM treatment and discharge prescription were 82% (233 of 285) and 69% (169 of 246) for patients with clinical acute symptomatic seizures, 96% (103 of 107) and 95% (61 of 64) for electrographic seizures, and 64% (233 of 364) and 48% (128 of 267) for EAs. On multivariable analysis, acute and progressive brain injuries were independently associated with increased odds of inpatient ASM treatment (odds ratio [OR], 3.86 [95% CI, 2.06-7.32] and 8.37 [95% CI, 3.48-20.80], respectively) and discharge prescription (OR, 2.26 [95% CI, 1.04-4.98] and 10.10 [95% CI, 3.94-27.00], respectively). Admission to the neurology or neurosurgery service (OR, 2.56 [95% CI, 1.08-6.18]) or to the neurological intensive care unit (OR, 7.98 [95% CI, 3.49-19.00]) was associated with increased odds of treatment. Acute symptomatic seizures and EAs were significantly associated with increased odds of ASM treatment (OR, 14.30 [95% CI, 8.52-24.90] and 2.30 [95% CI, 1.47-3.61], respectively) and discharge prescription (OR, 12.60 [95% CI, 7.37-22.00] and 1.72 [95% CI, 1.00-2.97], respectively). ASM treatment was not associated with outcomes at discharge (OR, 0.96 [95% CI, 0.61-1.52]) or at 3 months after initial presentation (OR, 1.26 [95% CI, 0.78-2.04]). Among 623 patients alive and with complete data at 3 months after discharge, 30 (5%) had postdischarge seizures, 187 (30%) were receiving ASMs, and 202 (32%) had all-cause readmissions. Conclusions and Relevance: This study suggests that etiology and electrographic findings are associated with ASM treatment for acute symptomatic seizures and EAs; ASM treatment was not associated with functional outcomes. Comparative effectiveness studies are indicated to identify which patients may benefit from ASMs and to determine the optimal treatment duration.

Late-onset epilepsy clinic: From clinical diagnostics to biomarkers.

The unique patho-clinical entity of late-onset epilepsy (LOE), distinguished by its distinct natural history, from its onset to the prognosis it portends, necessitates specialized care. We lack a universally accepted definition, but LOE is typically identified as epilepsy onset after the age of 60 or 65. Unlike epilepsy in younger individuals, LOE is almost by default focal in origin, secondary to acquired etiologies, and presents unique diagnostic and management challenges due to its atypical semiology, higher comorbidity burden, frailty, and increased risks of subsequent stroke and dementia. LOE clinics have been established to address these challenges, providing a multidisciplinary approach to optimize outcomes in patients with new-onset seizures beyond the fifth decade of life. LOE clinics are essential for comprehensive care, offering not only seizure management but also monitoring and addressing associated comorbidities. The care model involves collaboration among neurologists, primary care providers, cardiologists, mental health professionals, and social workers to manage LOE patients' complex needs effectively. The prevalence of cognitive dysfunction in LOE patients underscores the need for regular cognitive assessments and interventions. Biomarker research, particularly involving amyloid beta, offers promising avenues for early diagnosis and a better understanding of the interplay between LOE and Alzheimer's disease. Establishing LOE clinics in major referral centers can enhance provider expertise, improve patient outcomes, and facilitate research to advance diagnostic and therapeutic strategies. In conclusion, LOE clinics play a critical role in addressing the multifaceted needs of older adults with epilepsy, tailored to local resources and challenges, thus enhancing epilepsy care in an aging global population.

End of life care of hospitalized patients with Parkinson disease: a retrospective analysis and brief review.

Background: Towards the end of life (EOL), persons with parkinsonism (PwP) have complex needs and can present with unique palliative care (PC) challenges. There are no widely accepted guidelines to aid neurologists, hospitalists, or PC clinicians in managing the symptoms of PwP at EOL. We examined a population of PwP at EOL, aiming to describe trends of in-hospital management and utilization of PC services. Methods: All PwP admitted to two hospitals during 2018 (N = 727) were examined retrospectively, assessing those who died in hospital or were discharged with hospice (EOL group, N = 35) and comparing them to the main cohort. Their demographics, clinical data, engagement of multidisciplinary and palliative services, code status changes, invasive care, frequency of admissions, and medication administration were assessed. Results: Among the EOL group, 8 expired in hospital, and 27 were discharged to hospice. Forty-six percent of EOL patients received a PC consultation during their admission. The median interval from admission to death was 37 days. Seventy-seven percent had a full code status on admission. Compared to hospice patients, those who expired in hospital had higher rates of invasive procedures and intensive care unit transfers (41% vs. 75%, in both variables), and lower rates of PC involvement (52% vs. 25%). The transition of code status change for the EOL group from Full code to Do Not Resuscitate (DNR) occurred at a median 4-5 days from admission. For patients that passed in the hospital, the median days from transition of code status to death was 0(IQR 0-1). Levodopa dose deviations were frequent in both EOL and non-EOL group, but contraindicated medications were infrequently administered (11% in EOL group vs. 9% in non-EOL group). Conclusion: Our data suggest a low utilization of PC services and delayed discussions of goals of care. More work is needed to raise awareness of inpatient teams managing PwP regarding the unique but common challenges facing PwP with advanced disease. A brief narrative review summarizing the suggested management of symptoms common to hospitalized PwP near EOL is provided.

COVID-19 Vaccination and Neurological Manifestations: A Review of Case Reports and Case Series.

BACKGROUND: With 10 vaccines approved by the WHO and nearly 48% of people fully vaccinated worldwide, we have observed several individual case studies of neurological manifestations post-COVID-19 vaccination. Through this systematic review, we aim to discern these CNS and PNS manifestations following the COVID-19 vaccine to help produce methods to mitigate them. METHODS: We conducted a thorough literature search of Google Scholar and PubMed from 1 December 2020 until 10 October 2021 and included all the case studies of COVID-19 vaccine-associated neurological side effects. The literature search and data analysis were performed by two independent reviewers according to prespecified inclusion and exclusion criteria using PRISMA. RESULTS: The most common CNS manifestation was CVST (14.47%), found in females (64%) younger than 50 years (71%) after the first AstraZeneca dose (93%). Others included CNS demyelinating disorders (TM, ADEM, MS, NMOSD) (9.30%), encephalopathy/encephalitis (3.10%), and others (4.13%). The most common PNS manifestation was GBS (14.67%) found in males (71%) older than 50 years (79%), followed by Bell's palsy (5.24%) and others (2.10%). Most occurred with the AstraZeneca (28.55%), Pfizer-BioNTech (9.18%), and Moderna (8.16%) vaccines. Nine (64%) out of the 14 patients with CVST died. However, most cases overall (42 out of 51) were non-fatal (82%). CONCLUSION: Several CNS and PNS adverse events have occurred post-COVID-19 vaccination, including CVST, GBS, and TM. High vigilance with early identification and treatment leads to better outcomes. Further studies with non-vaccinated controls might help in understanding the pathophysiologic mechanisms of these neurological manifestations following COVID-19 vaccination.

Spectrum of hospitalized NeuroCOVID diagnoses from a tertiary care neurology centre in Eastern India.

PURPOSE: To describe the spectrum of hospitalized NeuroCOVID on admission in a tertiary neurology centre in Kolkata, the largest and most populated metropolitan city in Eastern India. METHOD: We retrospectively studied confirmed COVID-19 patients admitted with a neurological condition from 1st May 2020 to 30th January 2021. Neurological diagnoses and their temporal relationship to respiratory features along with clinicodemographic profile for such patients was ascertained. RESULT: 228 patients were diagnosed with NeuroCOVID at our centre. Of the 162 included population (median age was 59 (50-70) and 62.3% (101) were male) and 73.5% were diagnosed with NeuroCovid before any respiratory or febrile features. 46 patients (28.8%) had a pre/co-existing neurological illness, and 103 (63.6%) had systemic comorbidities. No significant difference was observed when comparing demographics and comorbidities of NeuroCOVID patients presenting with and without fever and respiratory features. Moreover, no individual NeuroCOVID diagnosis was more prone to present with respiratory or febrile features. Diabetes mellitus was the only comorbidity which was significantly higher in the ischemic stroke group, all other comorbidities and characteristics were evenly distributed between stroke and non-stroke NeuroCOVID patients and encephalopathy non encephalopathy NeuroCOVID patients. CONCLUSION: Stroke and encephalopathy are the most prevalent parainfectious neurological conditions occurring with COVID-19 in the Indian population. This study demonstrates seemingly low-risk individuals (i.e. people without pre-existing systemic and neurological comorbidities) may develop neurological conditions. Moreover, NeuroCOVID may manifest independent of respiratory features and fever.

A longitudinal quantitative analysis of gait in patients with SCA-12.

INTRODUCTION: Spinocerebellar ataxia type 12 (SCA 12) is characterized by late onset tremor, ataxia and pyramidal signs. Parkinsonism and cognitive decline may appear with time. It is considered as slowly progressive but temporal evolution of symptoms has not been reported. METHOD: We report the evolution of symptoms in three SCA12 patients followed over a range of 5-6 years. We focused on the evolution of gait abnormality as it becomes the most disabling symptom as disease advances. Two-dimensional gait parameters were studied using an electronic walkway at various time points to measure objective changes in gait. RESULT: All patients presented with tremor in the upper extremity at baseline which progressed non-uniformly over the years. Progression of gait variability measures of step length, stance time and step time were also observed. CONCLUSION: Gait characteristics such as variability may precede clinical gait abnormality and could serve as a sensitive marker for disease progression for better therapeutic intervention in disease management. Future studies with larger sample size should be undertaken to conclusively validate this observation.