Cold-Induced Reflex Epilepsy.

This case report describes a woman cold-induced reflex seizures.

Visualizing Hyperhidrosis With Water-Erasable Ink.

This case report describes the use of water-erasable ink to visualize hyperhidrosis in Frey syndrome.

Evaluating yield and utilization of ganglioside antibody testing in clinical practice.

BACKGROUND AND OBJECTIVES: Ganglioside antibodies can help diagnose distinct acute and chronic inflammatory neuropathies including axonal variants of Guillain-Barre syndrome, Miller-Fisher syndrome (MFS), multifocal motor neuropathy, and chronic sensory ataxic neuropathies. Because ganglioside antibody testing may be routinely ordered in patients with suspected inflammatory neuropathy, we sought to evaluate its yield and utilization in clinical practice. METHODS: We performed a retrospective chart review of all patients at London Health Sciences Centre who underwent ganglioside antibody testing between April 2019 and August 2023. The disease phenotype was determined for each patient, and the proportion of all tests that yielded a true-positive result was calculated. Ganglioside antibody positivity was classified as a true-positive result if the disease phenotype was robustly associated with the detected ganglioside antibody and there was no other more likely diagnosis. RESULTS: We identified 92 patients who underwent ganglioside antibody testing. One patient (1%) was classified as having a true-positive result; this patient had GQ1b-IgG positivity with MFS. Among 92 patients tested, 20 patients (22%) had a disease phenotype that was considered to be robustly associated with ganglioside antibody positivity. CONCLUSIONS: The yield of ganglioside antibody testing in clinical practice is low. We found that this testing is frequently ordered in patients with disease phenotypes that are not robustly associated with ganglioside antibody positivity, indicating that suboptimal test utilization is a primary contributor to its low yield. Restricting ganglioside antibody testing to patients with characteristic disease phenotypes would be valuable to improving yield and utilization of this testing.

Ophthalmoplegia With Isolated Extraocular Muscle Hypertrophy.

A 60-year-old man is experiencing diplopia but no problems with visual acuity, pain, or other symptoms. A magnetic resonance image of the head shows abnormal thickening and T2 hyperintensity of the right lateral rectus muscle. What is your diagnosis?

Insights From the Transition to Competency-Based Medical Education in Neurology Programs.

Canadian neurology residency programs recently transitioned to Competency-Based Medical Education (CBME). Iterative evaluation is required to optimize CBME implementation. This study aimed to examine the variability and challenges in uptake of CBME in neurology residency programs and identify its benefits and pitfalls. Neurology residents and faculty participated in respective anonymous surveys. Common barriers to uptake were identified from both perspectives. Orientation to CBME was adequate, but workload was increased and contributed to burnout for faculty and residents. It is premature to draw conclusions regarding benefits of CBME. Future research considerations include standardization of entrustment scales and reduction of stakeholder burden.

Neurologic Complications of Patients With COVID-19 Requiring Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis.

In COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO), our primary objective was to determine the frequency of intracranial hemorrhage (ICH). Secondary objectives were to estimate the frequency of ischemic stroke, to explore association between higher anticoagulation targets and ICH, and to estimate the association between neurologic complications and in-hospital mortality. DATA SOURCES: We searched MEDLINE, Embase, PsycINFO, Cochrane, and MedRxiv databases from inception to March 15, 2022. STUDY SELECTION: We identified studies that described acute neurological complications in adult patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection requiring ECMO. DATA EXTRACTION: Two authors independently performed study selection and data extraction. Studies with 95% or more of its patients on venovenous or venoarterial ECMO were pooled for meta-analysis, which was calculated using a random-effects model. DATA SYNTHESIS: Fifty-four studies (n = 3,347) were included in the systematic review. Venovenous ECMO was used in 97% of patients. Meta-analysis of ICH and ischemic stroke on venovenous ECMO included 18 and 11 studies, respectively. The frequency of ICH was 11% (95% CI, 8-15%), with intraparenchymal hemorrhage being the most common subtype (73%), while the frequency of ischemic strokes was 2% (95% CI, 1-3%). Higher anticoagulation targets were not associated with increased frequency of ICH (p = 0.06). In-hospital mortality was 37% (95% CI, 34-40%) and neurologic causes ranked as the third most common cause of death. The risk ratio of mortality in COVID-19 patients with neurologic complications on venovenous ECMO compared with patients without neurologic complications was 2.24 (95% CI, 1.46-3.46). There were insufficient studies for meta-analysis of COVID-19 patients on venoarterial ECMO. CONCLUSIONS: COVID-19 patients requiring venovenous ECMO have a high frequency of ICH, and the development of neurologic complications more than doubled the risk of death. Healthcare providers should be aware of these increased risks and maintain a high index of suspicion for ICH.

Standardizing T1-w/T2-w ratio images in trigeminal neuralgia to estimate the degree of demyelination in vivo.

BACKGROUND: Novel magnetic resonance (MR) imaging techniques have led to the development of T1-w/T2-w ratio images or "myelin-sensitive maps (MMs)" to estimate and compare myelin content in vivo. Currently, raw image intensities in conventional MR images are unstandardized, preventing meaningful quantitative comparisons. We propose an improved workflow to standardize the MMs, which was applied to patients with classic trigeminal neuralgia (CTN) and trigeminal neuralgia secondary to multiple sclerosis (MSTN), to assess the validity and feasibility of this clinical tool. METHODS: T1-w and T2-w images were obtained for 17 CTN patients and 17 MSTN patients using a 3 T scanner. Template images were obtained from ICBM152. Multiple sclerosis (MS) plaques in the pons were labelled in MSTN patients. For each patient image, a Gaussian curve was fitted to the histogram of its intensity distribution, and transformed to match the Gaussian curve of its template image. RESULTS: After standardization, the structural contrast of the patient image and its histogram more closely resembled the ICBM152 template. Moreover, there was reduced variability in the histogram peaks of the gray and white matter between patients after standardization (p < 0.001). MM intensities were decreased within MS plaques, compared to normal-appearing white matter (NAWM) in MSTN patients (p < 0.001) and its corresponding regions in CTN patients (p < 0.001). CONCLUSIONS: Images intensities are calibrated according to a mathematic relationship between the intensities of the patient image and its template. Reduced variability among histogram peaks allows for interpretation of tissue-specific intensity and facilitates quantitative analysis. The resultant MMs facilitate comparisons of myelin content between different regions of the brain and between different patients in vivo. MM analysis revealed reduced myelin content in MS plaques compared to its corresponding regions in CTN patients and its surrounding NAWM in MSTN patients. Thus, the standardized MM serves as a non-invasive, easily-automated tool that can be feasibly applied to clinical populations for quantitative analyses of myelin content.

Trigeminal neuralgia associated with multiple sclerosis: A multimodal assessment of brainstem plaques and response to Gamma Knife radiosurgery.

BACKGROUND: Gamma Knife radiosurgery (GKRS) is a minimally invasive procedure for trigeminal neuralgia secondary to multiple sclerosis (MS-TN). Patients with MS-TN experience suboptimal response rates to treatment, and the relationship between trigeminal microstructure and treatment outcome is poorly understood. OBJECTIVE: To characterize imaging features of MS-TN pain and GKRS response. METHODS: 3 T diffusion-weighted imaging (DWI), T1-w, T2-w, and fluid-attenuated inversion recovery (FLAIR) sequences were acquired for 18 MS-TN patients undergoing GKRS. Brainstem plaques were standardized into a common space to determine plaque distribution. Ratio of T1-w/T2-w or "myelin maps (MM)" was generated. Multi-tensor tractography was used to delineate the radiosurgical target (RT), root entry zone (REZ), and proximal pontine segment (PPS) of the trigeminal nerves. RESULTS: Laterality of MS-TN is associated with increased axial diffusivity at the PPS, whereas decreased MM at the PPS correlated with poor GKRS response. Preoperatively, GKRS responders have higher fractional anisotropy at the RT, higher axial diffusivity at the REZ, and higher MM intensities at the PPS. CONCLUSION: This study demonstrates that diffusivities and MM intensities are important correlates of pain and treatment response, respectively. Overall, preoperative multimodal assessment of the central trigeminal pathway is a better indicator of GKRS response than postoperative assessment of the reduction in fractional anisotropy peripherally.

A systematic review of strategies to improve appropriate use of opioids and to reduce opioid use disorder and deaths from prescription opioids.

BACKGROUND: Abuse of prescription opioids is a serious problem in North America. AIMS: The aim of this study was to conduct a systematic review of peer-reviewed and grey literature to examine existing strategies aimed at improving the appropriate use of prescription opioids and/or reducing the misuse, abuse, and diversion of these drugs. METHODS: The following electronic databases were searched to September 2015 without language restrictions: MEDLINE, EMBASE, PsycINFO, and CINAHL; the grey literature was searched to May 2014. Reference lists of retrieved papers were also searched. Studies were eligible if a strategy was implemented and its impact on at least one of the primary outcomes of interest (appropriate prescription opioid use; misuse, abuse, opioid use disorder, diversion; overdose) was measured. Standardized, prepiloted forms were used for relevance screening, quality appraisal, and data extraction. RESULTS: A total of 65 studies that assessed 66 distinct strategies were identified. Due to the heterogeneity of the strategies, a qualitative synthesis was conducted. Many studies combined more than one type of strategy and measured various types of outcomes. The strategies with most promising results involved education, clinical practices, collaborations, prescription monitoring programs, public campaigns, opioid substitution programs, and naloxone distribution. We also found strategies that had some unintended consequences after implementation. CONCLUSIONS: Our review identified successful strategies that have been implemented and evaluated in various jurisdictions. There is a need to replicate and disseminate these strategies where the problem of prescription opioid misuse and abuse has taken a toll on society.

Contexte: L'abus d'opïodes sur ordonnance est un problème grave en Amérique du Nord.But: Effectuer une revue systématique de la littérature examinée par des pairs eet de la littérature grise afin d'étudier les stratégies existantes pour améliorer l'usage approprié des opioïdes sur ordonnance ou réduire la mauvaise utilisation, l'abus ou le détournement de ces médicaments.Méthodes: Des recherches ont été effectuées sans aucune restriction de langue dans les bases de données électroniques suivantes : MEDLINE, EMBASE, PsycINFO et CINAHL jusqu'en septembre 2015 et dans la littérature grise jusqu'en mai 2014. Des recherches ont aussi été effectuées dans les listes de références des articles retenus. Les études étaient admissibles si une stratégie avait été mise en oeuvre et que son effet sur au moins un des principaux résultats étudiés (usage approprié des opioïdes sur ordonnance; mauvaise utilisation, abus, trouble de consommation ou détournement des opioïdes; surdose) avait été mesuré. Des formulaires normalisés et préalablement mis à l'essai ont été utilisés pour déterminer la pertinence et évaluer la qualité des études, et en extraire les données.Résultats: Au total, 65 études évaluant 66 stratégies distinctes ont été répertoriées. En raison de l'hétérogénéité des stratégies, une synthèse qualitative a été effectuée. De nombreuses études combinaient plus d'un type de stratégie et mesuraient divers types de résultats. Les stratégies dont les résultats étaient les plus prometteurs portaient sur l'éducation, les pratiques cliniques, les collaborations, les programmes de surveillance des ordonnances, les campagnes publiques, les programmes de substitution des opioïdes et la distribution de naloxone. Nous avons également trouvé des stratégies qui avaient eu des conséquences imprévues après leur mise en oeuvre.Conclusions: Notre revue a recensé des stratégies fructueuses mises en oeuvre et évaluées dans diverses juridictions. Ces stratégies doivent être reproduites et diffusées là où le problème de la mauvaise utilisation et de l'abus d'opioïdes sur ordonnance a eu un effet néfaste sur la société.