Alcohol for seizure induction in the epilepsy monitoring unit.

RATIONALE: Seizure induction techniques are used in the epilepsy monitoring unit (EMU) to increase diagnostic yield and reduce length of stay. There are insufficient data on the efficacy of alcohol as an induction technique. METHODS: We performed a retrospective cohort study using six years of EMU data at our institution. We compared cases who received alcohol for seizure induction to matched controls who did not. The groups were matched on the following variables: age, reason for admission, length of stay, number of antiseizure medications (ASM) at admission, whether ASMs were tapered during admission, and presence of interictal epileptiform discharges. We used both propensity score and exact matching strategies. We compared the likelihood of epileptic seizures and nonepileptic events in cases versus controls using Kaplan-Meier time-to-event analysis, as well as odds ratios for these outcomes occurring at any time during the admission. RESULTS: We analyzed 256 cases who received alcohol (median dose 2.5 standard drinks) and 256 propensity score-matched controls. Cases who received alcohol were no more likely than controls to have an epileptic seizure (X2(1) = 0.01, p = 0.93) or nonepileptic event (X2(1) = 2.1, p = 0.14) in the first 48 h after alcohol administration. For the admission overall, cases were no more likely to have an epileptic seizure (OR 0.89, 95 % CI 0.61-1.28, p = 0.58), nonepileptic event (OR 0.97, CI 0.62-1.53, p = 1.00), nor require rescue benzodiazepine (OR 0.63, CI 0.35-1.12, p = 0.15). Stratified analyses revealed no increased risk of epileptic seizure in any subgroups. Sensitivity analysis using exact matching showed that results were robust to matching strategy. CONCLUSIONS: Alcohol was not an effective induction technique in the EMU. This finding has implications for counseling patients with epilepsy about the risks of drinking alcohol in moderation in their daily lives.

Paraneoplastic limbic encephalitis following treatment with single-agent pembrolizumab for advanced gastroesophageal adenocarcinoma.

The use of immune checkpoint inhibitors is increasing in clinical practice. While they have provided significant benefit to many patients, a new category of adverse effects, immune-related adverse effects, has emerged with their use. These effects can range from mild to severe and affect nearly every organ system. A man in his 70swith metastatic gastro-oesophageal junction adenocarcinoma who received one cycle of third-line pembrolizumab presented after three episodes of transient left facial paresthesia, the last of which extended to the left extremities and disturbed peripheral vision of the left eye. He was found to have subclinical seizures and cerebrospinal fluid positive for Ma2/Ta paraneoplastic antibodies, consistent with paraneoplastic limbic encephalitis. We describe an unusual presentation of paraneoplastic limbic encephalitis. This case adds to the limited literature describing the association of paraneoplastic limbic encephalitis and treatment with immune checkpoint inhibitors as well as the observed associations with immune-related adverse events and treatment responses.

Potential New Cysteine Sparing Mutation in the NOTCH3 Gene in a Patient with Nonfamilial CADASIL-like Disease.

BACKGROUND: Several different mutations have been reported in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). We present a unique case with transversion not involving cysteine on neurogenic locus notch homolog protein 3 gene. CASE DESCRIPTION: We present a case of 65-year-old woman with new ischemic stroke resulting in right hemiparesis. She has previously suffered minor strokes at age 56, 58, and 60 years and migraine headaches between age 10 and 50 years. Magnetic resonance imaging demonstrated multifocal chronic ischemic infarctions with encephalomalacia in the left posterior parietal, parieto-occipital regions and the pons. An analysis of the protein sequence of notch 3 gene did not demonstrate any alterations characteristics of CADASIL disease. There was a deoxyribonucleic acid variant with transversion of alanine with tyrosine and change of histidine with leucine on notch 3 gene. None of the family members had any clinical manifestations suggestive of CADASIL. CONCLUSION: We report the first report of deoxyribonucleic acid variation in notch 3 gene associated with clinical features of CADASIL without any familial component.

Upright Catheter-Based Cerebral Angiography.

BACKGROUND: Several studies using Doppler ultrasound have suggested cerebral venous drainage is through paravertebral venous plexus due to the collapse of internal jugular veins in an upright position. METHODS: We present a technique of acquiring venographic images during an upright position as part of catheter-based angiography to provide additional information regarding cerebral venous diseases. Angiographic images in anteroposterior projection were acquired in lying position and after patients were placed at 60° using radiolucent supporting wedges on angiographic table. RESULTS: In the first patient, there was activation of the paravertebral venous plexus as supplemental venous drainage to right internal jugular vein and stenosis of left internal jugular vein in high cervical segment in the upright position. There was relative collapse of both internal jugular veins in the mid-cervical region. In the second patient, there was attenuation of contrast opacification of right posterior cervical veins and complete occlusion of right internal jugular vein proximal extracranial segment (high-grade stenosis in lying position). There was activation of additional supplemental drainage to left internal jugular vein including paravertebral venous plexus. In the third patient, there was exacerbation of stenoses of the left and right internal jugular veins proximal extracranial segment in the upright position (moderate stenoses in lying position). There was activation of additional supplemental drainage via paravertebral venous plexus to both internal jugular veins. CONCLUSION: Our results demonstrate prominent changes in venous drainage patterns during upright angiographic images. Further studies would have to identify the patients in whom additional information in the upright angiography may provide clinically relevant information.