The Benefit of Neuromuscular Blockade in Patients with Postanoxic Myoclonus Otherwise Obscuring Continuous Electroencephalography (CEEG).

Introduction. Myoclonus status epilepticus is independently associated with poor outcome in coma patients after cardiac arrest. Determining if myoclonus is of cortical origin on continuous electroencephalography (CEEG) can be difficult secondary to the muscle artifact obscuring the underlying CEEG. The use of a neuromuscular blocker can be useful in these cases. Methods. Retrospective review of CEEG in patients with postanoxic myoclonus who received cisatracurium while being monitored. Results. Twelve patients (mean age: 53.3 years; 58.3% male) met inclusion criteria of clinical postanoxic myoclonus. The initial CEEG patterns immediately prior to neuromuscular blockade showed myoclonic artifact with continuous slowing (50%), burst suppression with myoclonic artifact (41.7%), and continuous myogenic artifact obscuring CEEG (8.3%). After intravenous administration of cisatracurium (0.1 mg-2 mg), reduction in artifact improved quality of CEEG recordings in 9/12 (75%), revealing previously unrecognized patterns: continuous EEG seizures (33.3%), lateralizing slowing (16.7%), burst suppression (16.7%), generalized periodic discharges (8.3%), and, in the patient who had an initially uninterpretable CEEG from myogenic artifact, continuous slowing. Conclusion. Short-acting neuromuscular blockade is useful in determining background cerebral activity on CEEG otherwise partially or completely obscured by muscle artifact in patients with postanoxic myoclonus. Fully understanding background cerebral activity is important in prognostication and treatment, particularly when there are underlying EEG seizures.

Medical Decision Making: Hyposphagma Prior to Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke.

The decision to administer intravenous tissue plasminogen activator (IV tPA) is based on standard exclusion and inclusion criteria, which include laboratories, imaging, and time of last known well. When patients present with a clinical scenario that is not addressed in these standards, the decision to administer IV tPA is more complex. We present a case of a patient with an acute stroke syndrome that also included acute subconjunctival hemorrhage (i.e., hyposphagma). We provide the medical decision making that occurred prior to the administration. Ultimately, the finding of hyposphagma should not disqualify eligible patients from receiving IV tPA.

Refractory Fulminant Acute Disseminated Encephalomyelitis (ADEM) in an Adult.

Acute disseminated encephalomyelitis (ADEM) is characterized by its rapid progression with variable symptoms and severity in adults and children. Multiple therapeutic options have been proposed, but solid evidence is yet to be gathered. We describe an adult man with a fulminant form of ADEM unresponsive to numerous treatment modalities.

Pearls on primary stroke center.

Stroke is a leading cause of morbidity and mortality in the United States. The Brain Attack Coalition (BAC) provided goals and standards for development of primary and comprehensive stroke centers. There are over 800 primary stroke centers certified by The Joint Commission. This article provides a practical summary of recommendations to develop a primary stroke center, including some pearls that result from the experience of our institution in the field.

Late onset CNS immune reconstitution inflammatory syndrome in an immunocompetent patient.

Immune reconstitution inflammatory syndrome (IRIS) refers to the presence of paradoxical clinical deterioration attributable to immune system recovery during highly active antiretroviral therapy (HAART). We present an immunocompetent patient with multifocal leukoencephalopathy on HAART, with central nervous system (CNS) IRIS pathology of unknown infectious etiology. CNS IRIS pathology should be suspected in patients on longstanding HAART without immune reconstitution, presenting with unexplained leukoencephalopathy.

Central and extrapontine myelinolysis affecting the brain and spinal cord. An unusual presentation of pancreatic encephalopathy.

Pancreatic encephalopathy refers to a gamut of neuropsychiatric symptoms complicating acute pancreatitis. Osmotic myelinolysis is a known complication of pancreatic encephalopathy. We evaluated a 58-year-old woman with pancreatic encephalopathy associated to pontine and extrapontine myelinolysis involving the brain and spinal cord. To our knowledge, this is the first clinic pathological case report of pancreatic encephalopathy involving the spinal cord.

Diabetic peripheral neuropathy and the management of diabetic peripheral neuropathic pain.

Diabetic peripheral neuropathy (DPN) affects approximately half of patients with diabetes. Neuropathic pain is a major complaint of patients with diabetic polyneuropathy. Diabetic peripheral neuropathy can also lead to autonomic dysfunction. This article provides an outline of the clinical subtypes, pathophysiological features, and diagnosis of DPN. Disease-modifying treatments are reviewed, with particular attention paid to DPN pain management.

Cocaine induced hippocampi infarction.

A middle age man presented with disorientation and memory impairment due to bilateral hippocampal strokes secondary to cocaine use. This is the second report of cocaine induced hippocampi ischaemic strokes. In contrast to the previous report, this middle age man did not have cardiac arrest.

Wegener's disease presenting with occipital condyle syndrome.

Tumors or chronic inflammatory lesions of the occipital condyle may cause occipital pain associated with an ipsilateral hypoglossal nerve injury (occipital condyle syndrome). We describe a young woman with recurrent otitis media and occipital condyle syndrome associated with a limited form of Wegener's disease.