New-Onset Non-convulsive Status Epilepticus in Previously Healthy COVID-19 Patient.

The novel severe acute respiratory syndrome (SARS-CoV-2) virus has spread rapidly worldwide in the last several year. COVID-19 presentation ranges widely from asymptomatic to acute respiratory failure. Interestingly, although neurological manifestations of COVID-19 have often been described in the literature, only a few cases reports describe status epilepticus associated with COVID-19 patients. This is a case of a 52-year-old previously healthy woman who presented to the emergency department with fever, worsening cough, shortness of breath, and hypoxia. She was found to be COVID-19-positive. She developed a bilateral tonic-clonic seizure 16 days after her first symptoms appeared. Continuous video encephalogram (CEEG) showed a generalized periodic pattern with triphasic morphology. This finding is suggestive of non-convulsive status epilepticus which resolved after valproic acid loading as given. The patient is fully recovered at 6 months follow-up and seizure-free on levetiracetam 750 mg twice daily. This case demonstrates a new onset of bilateral tonic-clonic seizure followed by non-convulsive status epilepticus associated with COVID-19 infection. As the spectrum of COVID-19 neurological manifestation has yet to be established, healthcare providers should be cognizant of the possibility of non-convulsive status epilepticus in COVID-19 patients in order to provide timely workup and management.

Training in Neurology: How Lessons Learned on Teaching, Well-being and Telemedicine During the COVID-19 Pandemic Can Shape the Future of Neurology Education.

The COVID-19 pandemic has a disruptive impact on neurology education, necessitating creative adjustments in the delivery of education, clinical training and wellbeing. In this piece, a group of educators reflects on challenges and lessons learnt on teaching, wellbeing and telemedicine, and how these can shape the future of neurology education. Developing standardized, rigorous evaluation of teaching methods and telemedicine, reinforcing wellbeing resources and promoting international educational collaborations can improve neurology training during and after the pandemic.

Insulo-opercular cortex generates oroalimentary automatisms in temporal seizures.

OBJECTIVE: Oroalimentary automatisms (OAAs) resembling normal alimentary behavior are stereotyped complex movements that may occur during epileptic seizures. They are considered common clinical signs in temporal lobe seizures, but their anatomofunctional mechanisms are not established. We took the opportunity of presurgical intracerebral recordings to study the relations between the occurrence of OAAs and temporal/spatial features of ictal activities. METHODS: We retrospectively reviewed patients with medically intractable medial temporal lobe epilepsy who underwent stereoelectroencephalography (SEEG) at Cleveland Clinic between 2009 and 2016. Patients presenting oroalimentary automatisms during seizures, with intracerebral electrodes spanning temporal and extratemporal areas, were selected. SEEG-clinical correlations with latency measurements were done. Coherence analyses were performed on regions of interest as defined by the areas involved at the onset of oroalimentary automatisms. RESULTS: Fifteen patients (115 seizures) were analyzed. Sixty-nine seizures exhibited overt oroalimentary automatisms. Only insulo-opercular cortex ictal involvement was consistently related to the occurrence of OAAs, with a linear correlation between OAA onset and ictal oscillatory activity onset in the insulo-opercular cortex. SEEG signal processing showed an increase in theta coherence preceding oroalimentary automatism onset between mediobasal-temporal structures and insulo-opercular cortex, as well as between the 2 insulo-opercular regions. SIGNIFICANCE: The underlying mechanism for the production of oroalimentary automatisms in medial temporal seizures is based on temporal-insulo-opercular theta coherence leading to a synchronous state generating rhythmic patterned outputs from the cortical masticatory area.

Unusual case of intra-arterial doxorubicin chemoembolization-associated posterior reversible encephalopathy syndrome.

A 63-year-old white female with a history of metastatic breast cancer to the liver developed acute-onset nausea, vomiting, mental status change, and generalized seizures following transarterial chemoembolization using doxorubicin. The patient was hospitalized with the above symptoms immediately following transarterial chemoembolization using drug eluting bead doxorubicin into the right hepatic artery. The patient developed intractable nausea, vomiting, and abdominal pain and had a generalized tonic-clonic seizure lasting for 40 seconds, approximately 24 hours after the procedure. The patient was confused and lethargic for 2 days with progressive improvement in her mental status. Her neurological examination showed encephalopathy with disorientation to time, place or person, and she also had a glassy look. Cranial nerves were normal other than lack of response to threat stimulus bilaterally; motor and sensory examination was unremarkable. Initial blood pressure was 130/90 mm Hg and routine chemistry and complete blood count on admission were within normal limits. The cerebrospinal fluid analysis showed clear and colorless fluid with glucose of 56 mg/dL, protein of 42 mg/dL, white blood cells of 2/µL, and red blood cells of 10/µL and did not show any evidence of infectious or toxic etiology on encephalopathy. Continuous electro encephalography showed diffuse slowing but no epileptiform discharges. The magnetic resonance imaging (MRI) revealed increased signal intensity in the bilateral parieto-occipital area, right more than the left, on fluid-attenuated inversion recovery, apparent diffusion coefficient, and T2-weighted imaging, with no increased signal on diffusion weighted image consistent with vasogenic edema. The patient's symptoms and MRI findings were consistent with diagnosis of posterior reversible encephalopathy syndrome. Resolution of the MRI changes is noted on the follow-up imaging 8 weeks later. Posterior reversible encephalopathy syndrome in this case is most likely related to intra-arterial doxorubicin infusion because of the temporal association between administration, symptom onset, and MRI changes.

Drug evaluation of clevidipine for acute hypertension.

BACKGROUND: Clevidipine is an investigational agent undergoing late-stage clinical development to evaluate its potential as a novel short-acting intravenous agent for treating acute hypertension, either in hypertensive emergencies encountered in the emergency department and intensive care units, or in the perioperative period. METHOD: Clevidipine has been evaluated in four Phase I studies, nine Phase II studies and six Phase III clinical studies. The patient populations studied include healthy volunteers, patients with essential hypertension, patients undergoing cardiac surgery, and patients presenting to the emergency department with hypertensive emergencies. Studies providing comparative data of clevidipine versus nitroglycerin, nicardipine or sodium nitroprusside are also available. OBJECTIVE: This article reviews the results of clinical studies evaluating the pharmacological properties, clinical effects and safety profiles of clevidipine in various patient populations. RESULTS/CONCLUSION: Clevidipine is an effective agent for reducing acute elevation in blood pressure in various settings, including hypertensive emergencies and perioperative hypertension with a good safety profile.