Early cerebral venous drainage associated with focal seizures: a correlation of digital subtraction angiography and electroencephalography. Illustrative case.

BACKGROUND: Early venous drainage is a critical diagnostic feature of arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs). However, other conditions associated with early venous drainage can mimic AVMs and AVFs and mislead the treating physician team. OBSERVATIONS: The authors present a unique case of a 56-year-old man with new left hemianopsia. Workup with magnetic resonance imaging and magnetic resonance angiography had revealed cortical enhancement and early venous drainage, possibly caused by an AVF or AVM. Catheter angiography confirmed the presence of early venous drainage of specifically the right occipital lobe. The early venous drainage occurred as the result of local hyperperfusion limited to the right occipital lobe. Subsequent electroencephalography confirmed focal seizure activity in the right occipital lobe. After seizure control with multiple antiepileptic medications, the patient regained his vision. Repeat digital subtraction angiography revealed restoration of normal cerebral blood flow. LESSONS: Early venous drainage observed during catheter angiography can be associated with seizure activity. Differentiation from other conditions, such as AVM, AVF, or ischemic stroke, is critical to facilitate prompt and appropriate treatment.

Neuropsychological normative standards for late career physicians.

Objective: In the context of an aging, vital physician workforce, there is clear value in establishing a specialized neuropsychological normative dataset for the evaluation of late career physicians practicing clinical medicine. Methods: Physicians aged 60 and over in active clinical practice at 3 major medical centers in North Carolina were recruited to complete a comprehensive neuropsychological test battery. Results: The sample (n = 100) was aged 60-78. Reflecting medical school distributions for this age group, the sample was mostly male (76%) and was fairly racially homogenous (96% White). To amplify utility of the dataset, data were obtained for several measures across neurocognitive domains. Results are presented in percentile bands stratified by age and sex where needed, and regression formulas are presented for predictive precision for measures where both age and sex predicted performance. Important distinctions between our sample, the general population, and current comparative demographic norms were also confirmed. Conclusions: Here we present a preliminary normative dataset on a comprehensive neuropsychological test battery for late career physicians, the HEATS norms for highly educated aging treaters. These standards facilitate accurate, objective cognitive measurement as a part of clinical diagnostic and capacity evaluations. Co-norming the battery in a single, specialized sample further augments its utility in characterizing cognition. Future work to enhance the dataset to be maximally applicable across demographic groups is anticipated, as is research to explore the relationship between these standards and professional performance outcomes.

Loss of Vestibular Ocular Reflex in Nonconvulsive Status Epilepticus.

BACKGROUND: Electroencephalogram (EEG) findings of generalized periodic discharges (GPDs) with triphasic morphology were introduced as a metabolic phenomenon, but more recently have been associated with epileptic phenomenon. Resolution of EEG findings along with clinical improvement from treatment is diagnostic. The known causes of reversible, isolated loss of OVR include medication toxicity, lead exposure, and thiamine deficiency, but its association with nonconvulsive status epilepticus (NCSE) has never been published. Medication induced loss of OVR resolves after a 24-hour washout period. We report a case of reversible, isolated loss of vestibular ocular reflex (VOR) associated with epileptic phenomenon. METHODS: This is a case report of a single patient. RESULTS: A 74-year-old male with a history of complex partial seizures admitted for a pneumonectomy had a post-operative course complicated by two instances of coma, the latter associated with an isolated loss of VOR. EEG revealed GPDs with triphasic morphology initially interpreted as a metabolic phenomenon. The patient's mental status, exam and EEG findings improved after low dose infusion of propofol for tracheostomy, and he was eventually discharged at baseline neurological function. Due to this response, his coma, loss of VOR and EEG were later interpreted as a consequence of NCSE. CONCLUSION: The interpretation of GPDs with triphasic wave morphology range from metabolic phenomenon to NCSE. NCSE should be highly considered on the differential for encephalopathy regardless of the circumstances. NCSE may be a potential cause of reversible, isolated loss of the VOR and an AED trial in the appropriate clinical context should be considered. This is the first report of loss of VOR possibly associated with NCSE.

Emerging Subspecialties in Neurology: Sports neurology training and certification: An overview in 2018.

Sports neurology is a relatively new specialty in neurology. Interested trainees may find it difficult to learn about issues in sports neurology both in medical school and residency. This review highlights what the current state is in medical school and residency training and how an interested trainee or neurologist could pursue a career in this area.

The Duke neurology advanced practice provider residency: Its time has come.

The acknowledgment that specialization in neurology based on a clinician's extensive background in neuroscience contributes to expertise in patient care was a motivating factor in developing neurology residency programs. The increasing demand for more and better access to neurologic care has created a health care environment ripe for innovation. Advanced practice providers currently do not have the opportunity during primary training to gain much experience in neurologic care. We discuss the challenges and benefits of developing a 1-year neurology residency program for nurse practitioner and physician assistant graduates at our institution. We propose that providing advanced practice providers with specialty skills through neurology residency programs such as ours will be integral to meet the growing clinical need for neurologic care.

Time to diagnosis in the National Registry of Veterans with Amyotrophic Lateral Sclerosis.

Our objective was to determine the interval from symptom onset to diagnosis, and to evaluate associated factors in a cohort of U.S. Veterans with motor neuron diseases. We retrospectively evaluated 1359 patients enrolled in the National Registry of Veterans with Amyotrophic Lateral Sclerosis (ALS). The main outcome measures were time from symptom onset to first diagnosis and to second opinion. Predictor variables included age at symptom onset, year of symptom onset, race, onset site, final diagnosis, number of diagnostic tests performed and clinical sites visited. Median time to first diagnosis was 11 months; median time to second opinion was two months. In a multivariable model, more recent calendar year of symptom onset, younger age, bulbar onset and a diagnosis of ALS versus non-ALS motor neuron disease were all significantly associated with a shorter time to first diagnosis. Later year of symptom onset and white race were significantly associated with a shorter time to second opinion. While the interval from symptom onset to diagnosis, and many of the associated factors are similar between our large cohort of U.S. Veterans with ALS and other smaller published cohorts, we found that the diagnostic interval among U.S. Veterans has significantly decreased over time.

Factors associated with survival in the National Registry of Veterans with ALS.

The clinical course of patients with ALS is highly variable. While the median survival time from symptom onset is 2-4 years, there are reports of survival ranging from less than a year to more than 40 years. Such variability makes planning difficult for patients and physicians, and complicates clinical trial design. We sought to validate previous predictors of survival and search for new ones using a large group of ALS patients in the National Registry of Veterans with ALS. We were especially interested in how various aspects of military service might affect survival. Subjects were those in the National Registry of Veterans with ALS who had probable or definite ALS (according to El Escorial criteria). A multivariable Cox proportional hazard regression model was used to examine variables for statistical association with ventilator-free survival time (determined from date of first diagnosis). Subjects who had not died or started ventilation by 31 October 2006 were censored. Our group of 1085 US military veterans with ALS was primarily male (98%) and white (94%), with mostly sporadic (95%) and extremity-onset (76%) ALS. Symptom onset occurred at a mean age of 59.3 years (60.6 years for diagnosis). Median survival time from symptom onset was 4.7 years (3.3 years from diagnosis). In our multivariable model, older age at diagnosis (HR 1.41 (95% CI 1.27-1.55) per 10-year increase), non-extremity site of onset (HR 1.55 (1.24-1.94)), and past deployment to Vietnam (HR 1.73 (1.36-2.19)) were all associated with shortened survival. A longer time to diagnosis was associated with better survival (HR 0.77 (0.70-0.84) per one year increase in diagnosis time). In this unique cohort of veterans with ALS, traditional factors of reduced survival remained important. In addition, past deployment to Vietnam was found to be associated with shortened survival as well. This finding could be due to a common exposure, a shared characteristic, an unmeasured confounder, or an enrollment bias. More research will be needed to understand the reasons behind this new finding.

Adult cases of leukoencephalopathy, cerebral calcifications, and cysts: expanding the spectrum of the disorder.

Leukoencephalopathy with cerebral calcifications and cysts (LCC) was first reported in children who developed cognitive decline and variable extrapyramidal, cerebellar, and pyramidal signs, with or without seizures. Leukoencephalopathy with cerebral calcifications and cysts is characterized by progressive formation of brain cysts that can generate a mass effect simulating a neoplasm. Retinal changes that overlap with Coats disease, a microangiopathy with retinal telangiectasias and exudates, may also occur. We and others have reported LCC cases in adults. Neuroimaging shows diffuse leukoencephalopathy, multifocal calcifications especially of deep gray and white matter, multifocal enhancement, and variably sized cysts that may require surgical decompression. Biopsies adjacent to cysts have shown angiomatous and/or severely hyalinized blood vessels surrounded by myelin loss and gliosis, calcifications, and Rosenthal fibers. We report 2 additional adult-onset cases of LCC. Case 1 is a 40-year-old man who developed neurological symptoms and cirrhosis and died of acute gastrointestinal bleeding; he had numerous retinal microinfarcts at autopsy. Case 2 is a 55-year-old woman who was found by chance to have LCC; one and a half years later, her course remains benign. These cases expand the spectrum of adult-onset LCC, the etiology of which is unknown.

Friday night palsy: an unusual case of brachial plexus neuropathy.

Brachial plexopathy can result from traction injury, radiation injury, local or metastatic cancer, hereditary, or idiopathic causes. However, brachial plexopathy resulting from malposition of an arm during sleep, similar to Saturday night palsy, has not been reported. We report a case of brachial plexus neuropathy that occurred after the patient slept on his shoulder and arm following excessive alcohol consumption on a Friday night.

Video/EEG monitoring in the evaluation of paroxysmal behavioral events: duration, effectiveness, and limitations.

To establish the number of monitoring days needed to distinguish psychogenic nonepileptic seizures (PNES) from epileptic seizures (ES) in adult patients admitted for video/EEG monitoring (VEM), we performed a retrospective chart review on 199 consecutive admissions for behavioral event diagnosis with VEM. Of the 199 adult patients admitted for VEM, 83.9% (n = 167) had a clinical event during admission, and a definitive diagnosis was made in 75.9% (n = 151). Of patients who had clinical events, 87.7% (n = 143) had their first event on admission day 1 or 2. Factors associated with ES (vs PNES) included an abnormal baseline EEG (P < 0.001), an abnormal brain MRI (P = 0.01), and history of events lasting less than 1minute (P = 0.01). There was no association between time to first event and discharge diagnosis. VEM differentiated between ES and PNES in the majority of adult patients evaluated. Most behavioral events were characterized within 2 days of admission.

APOE2 allele increased in tardive dyskinesia.

Ninety-seven inpatients with tardive dyskinesia (average AIMS score = 13), the majority of whom were schizophrenic, were studied. Forty patients were Caucasian, and 57 were African-American. The APOE genotypes of these patients were compared to previously published genotypes of controls and with previously published studies of APOE genotypes in patients with schizophrenia. There were no significant differences in APOE allele frequencies comparing the African-American tardive dyskinesia population and the African-American control groups. In contrast, significant (< 0.05) P values were obtained comparing the Caucasian tardive dyskinesia population to the Caucasian controls, when comparing allele frequencies and genotypic frequencies. This study suggests that Caucasians bearing an APOE2 allele are at increased risk of developing tardive dyskinesia, whereas African-Americans are not. APOE genotype-specific risks of both tardive dyskinesia and Alzheimer's disease that vary across populations could be due to recruitment of patients or controls or could be due to modifying effects of differing genetic or environmental backgrounds. The mechanism by which the APOE2 allele increases risk of tardive dyskinesia is not known. Further information about the mechanisms of increased risk of tardive dyskinesia could result in stratification of prescribing practices weighing the costs of medications against the relative risk of side effects.

The impact of bispectral index monitoring on rates of propofol administration.

The purpose of this article is to examine the efficacy of Bispectral Index (BIS) monitoring as a tool for adjusting the amount of propofol patients receive to maintain a safe and adequate level of sedation in a neurocritical care setting. The BIS monitor is utilized as an adjunct for anesthesia monitoring in the operating room setting and is currently being investigated as a tool for objective sedation monitoring in the critical care setting. 1-6 Sedation is discussed in terms of patient safety and comfort. A secondary data analysis was used to test the hypothesis that BIS monitoring provides a more objective form of sedation assessment that will lead to a decrease in overall rates of propofol administration and fewer incidences of oversedation. Data were abstracted from a quality improvement study of propofol use adjusted to BIS values in patients whose sedation levels were previously adjusted to a goal Ramsay score. The results suggest that there are potential benefits to incorporating BIS into routine sedation assessment in the neurocritical care setting.

Lumbar puncture and CSF examination.

Preview Dr Morgenlander provides answers to some of the questions primary care physicians may have about lumbar puncture and cerebrospinal fluid (CSF) examination: What can be done to prevent post-lumbar puncture headache and how should it be treated? Does CSF pleocytosis in a patient who has had a seizure necessarily signify an underlying infectious or inflammatory process? Should every patient with dementia undergo CSF examination?