Treatment of Refractory Status Epilepticus With Continuous Intravenous Anesthetic Drugs: A Systematic Review.

Importance: Multiple continuous intravenous anesthetic drugs (CIVADs) are available for the treatment of refractory status epilepticus (RSE). There is a paucity of data comparing the different types of CIVADs used for RSE. Objective: To systematically review and compare outcome measures associated with the initial CIVAD choice in RSE in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Evidence Review: Data sources included English and non-English articles using Embase, MEDLINE, PubMed, and Web of Science (January 1994-June 2023) as well as manual search. Study selection included peer-reviewed studies of 5 or more patients and at least 1 patient older than 12 years with status epilepticus refractory to a benzodiazepine and at least 1 standard antiseizure medication, treated with continuously infused midazolam, ketamine, propofol, pentobarbital, or thiopental. Independent extraction of articles was performed using prespecified data items. The association between outcome variables and CIVAD was examined with an analysis of variance or χ2 test where appropriate. Binary logistic regressions were used to examine the association between outcome variables and CIVAD with etiology, change in mortality over time, electroencephalography (EEG) monitoring (continuous vs intermittent), and treatment goal (seizure vs burst suppression) included as covariates. Risk of bias was addressed by listing the population and type of each study. Findings: A total of 66 studies with 1637 patients were included. Significant differences among CIVAD groups in short-term failure, hypotension, and CIVAD substitution during treatment were observed. Non-epilepsy-related RSE (vs epilepsy-related RSE) was associated with a higher rate of CIVAD substitution (60 of 120 [50.0%] vs 11 of 43 [25.6%]; odds ratio [OR], 3.11; 95% CI, 1.44-7.11; P = .006) and mortality (98 of 227 [43.2%] vs 7 of 63 [11.1%]; OR, 17.0; 95% CI, 4.71-109.35; P < .001). Seizure suppression was associated with mortality (OR, 7.72; 95% CI, 1.77-39.23; P = .005), but only a small subgroup was available for analysis (seizure suppression: 17 of 22 [77.3%] from 3 publications vs burst suppression: 25 of 98 [25.5%] from 12 publications). CIVAD choice and EEG type were not predictors of mortality. Earlier publication year was associated with mortality, although the observation was no longer statistically significant after adjusting SEs for clustering. Conclusions and Relevance: Epilepsy-related RSE was associated with lower mortality compared with other RSE etiologies. A trend of decreasing mortality over time was observed, which may suggest an effect of advances in neurocritical care. The overall data are heterogeneous, which limits definitive conclusions on the choice of optimal initial CIVAD in RSE treatment.

Ventriculostomy Associated with Reduced Mortality in Severe Traumatic Brain Injury Compared to Parenchymal ICP Monitoring: A Propensity Score-Adjusted Analysis.

BACKGROUND: There is a lack of data on whether intracranial pressure (ICP)-guided therapy with an intraparenchymal fiberoptic monitor (IPM) or an external ventricular drain (EVD) leads to superior outcomes. Our goal is to determine the relationship between ICP-guided therapy with an EVD or IPM and mortality. METHODS: Retrospective analysis of severe traumatic brain injury cases that required IPM or EVD placement for ICP-guided therapy from January 1, 2010 to December 31, 2020. The data were obtained from the Pennsylvania Trauma Systems Foundation registry. RESULTS: A total of 2305 patients met the inclusion criteria, with 1048 (45.5%) IPM and 1257 (54.5%) EVD placed. Inpatient mortality occurred in 337 (32.2%) and 334 (26.6%) patients in the IPM and EVD cohorts, respectively (P = 0.003). Even among those treated medically only, inpatient mortality occurred in 171 (30.8%) of those with an IPM and in 100 (23.4%) of those with an EVD (P = 0.010). Multivariable logistic regression analysis showed that older age (odds ratio [OR] 1.03, P < 0.001), lower Glasgow Coma Scale (GCS) score (OR 1.16, P < 0.001), requiring surgery (OR 1.22, P = 0.049), and an IPM (OR 1.40, P = 0.001) were significant predictors of mortality. Propensity score-adjusted analysis using inverse probability of treatment weighted method revealed a 28% decrease in mortality and a 14% decrease in length of hospital stay with EVD use when adjusting for age, sex, GCS, Injury Severity Score, surgery, and Hispanic ethnicity. CONCLUSIONS: A significant mortality benefit was associated with the use of EVD compared to IPM. This mortality benefit was observed regardless of whether patients required surgery or not.

The SLANT Score Predicts Poor Neurologic Outcome in Comatose Survivors of Cardiac Arrest: An External Validation Using a Retrospective Cohort.

BACKGROUND: Hypoxic brain injury is the leading cause of death in comatose patients following resuscitation from cardiac arrest. Neurological outcome can be difficult to prognosticate following resuscitation, and goals of care discussions are often informed by multiple prognostic tools. One tool that has shown promise is the SLANT score, which encompasses five metrics including initial nonshockable rhythm, leukocyte count after targeted temperature management, total adrenaline dose during resuscitation, lack of bystander cardiopulmonary resuscitation, and time to return of spontaneous circulation. This cohort study aimed to provide an external validation of this score by using a database of comatose cardiac arrest survivors from our institution. METHODS: We retrospectively queried our database of cardiac arrest survivors, selecting for patients with coma, sustained return of spontaneous circulation, and use of targeted temperature management to have a comparable sample to the index study. We calculated SLANT scores for each patient and separated them into risk levels, both according to the original study and according to a Youden index analysis. The primary outcome was poor neurologic outcome (defined by a cerebral performance category score of 3 or greater at discharge), and the secondary outcome was in-hospital mortality. Univariable and multivariable analyses, as well as a receiver operator characteristic curve, were used to assess the SLANT score for independent predictability and diagnostic accuracy for poor outcomes. RESULTS: We demonstrate significant association between a SLANT group with increased risk and poor neurologic outcome on univariable (p = 0.005) and multivariable analysis (odds ratio 1.162, 95% confidence interval 1.003-1.346, p = 0.046). A receiver operating characteristic analysis indicates that SLANT scoring is a fair prognostic test for poor neurologic outcome (area under the curve 0.708, 95% confidence interval 0.536-0.879, p = 0.024). Among this cohort, the most frequent SLANT elements were initial nonshockable rhythm (84.5%) and total adrenaline dose ≥ 5 mg (63.9%). There was no significant association between SLANT score and in-hospital mortality (p = 0.064). CONCLUSIONS: The SLANT score may independently predict poor neurologic outcome but not in-hospital mortality. Including the SLANT score as part of a multimodal approach may improve our ability to accurately prognosticate comatose survivors of cardiac arrest.

Declining Intensive Care Unit Mortality of COVID-19: A Multi-Center Study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) mortality has waned significantly over time; however, factors contributing towards this reduction largely remain unidentified. The purpose of this study was to evaluate the trend in mortality at our large tertiary academic health system and factors contributing to this trend. METHODS: This is a retrospective cohort study of intensive care unit (ICU) patients diagnosed with COVID-19 between March and August 2020 admitted across 14 hospitals in the Philadelphia area. Collected data included demographics, comorbidities, admission risk of mortality score, laboratory values, medical interventions, survival outcomes, hospital and ICU length of stay (LOS) and discharge disposition. Chi-square (χ2) test, Fisher exact test, Cochran-Mantel-Haenszel method, multinomial logistic regression models, independent sample t-test, Mann-Whitney U test and one-way analysis of variance (ANOVA) were used. RESULTS: A total of 1,204 patients were included. Overall mortality was 39%. Mortality declined significantly from 46% in March to 14% in August 2020 (P < 0.05). The most common underlying comorbidities were hypertension (60.2%), diabetes mellitus (44.7%), dyslipidemia (31.6%) and congestive heart failure (14.7%). Hydroxychloroquine (HCQ) use was more commonly associated with the patients who died, while the use of remdesivir, tocilizumab, steroids and duration of these medications were not significantly different. Peak values of ferritin, lactate dehydrogenase (LDH), C-reactive protein (CRP) and D-dimer levels were significantly higher in patients who died (P < 0.05). The mean hospital LOS was significantly longer in the patients who survived compared to the patients who died (18 vs. 12, P < 0.05). CONCLUSIONS: The mortality of patients admitted to our ICU system significantly decreased over time. Factors that may have contributed to this may be the result of a better understanding of COVID-19 pathophysiology and treatments. Further research is needed to elucidate the factors contributing to a reduction in the mortality rate for this patient population.

Rapid Decline in Telestroke Consults in the Setting of COVID-19.

Background and Purpose: As coronavirus disease 2019 (COVID-19) continues to be a global pandemic, there is a growing body of evidence suggesting that incidence of diseases that require emergent care, particularly myocardial infarction and ischemic stroke, has declined rapidly. The objective of this study is to quantify our experience of telestroke (TS) consults at a large tertiary comprehensive stroke center during the COVID-19 pandemic. Methods: We retrospectively reviewed TS consults of patients presenting to our neuroscience network. Those with a confirmed diagnosis of acute ischemic stroke or transient ischemia attack were included. Data were compared from April 1, 2019, to June 30, 2020, which include consults prepandemic and during the crisis. Results: A total of 1,982 TS consults were provided in 1 year. Prepandemic, the mean monthly consults were 148. In April 2020, only 59 patients were seen (49% decline). Mobile stroke unit consults decreased by 72% in the same month. The 30-day moving average of patients seen per day was between five and six prepandemic declined to between two and three in April, and then began to uptrend during May. The mean percentage of patients receiving intravenous tissue plasminogen activator was 16% from April 2019 to March 2020 and increased to 31% in April 2020. The mean percentage of patients receiving endovascular therapy was 10% from April 2019 to March 2020 and increased to 19% in April 2020. Conclusions: At our large tertiary comprehensive stroke center, we observed a significant and rapid decline in TS consults during the COVID-19 pandemic. We cannot be certain of the reasons for the decline, but a fear of contracting coronavirus, social distancing, and isolation likely played a major role. Further research must be done to elucidate the etiology of this decline.

Ultra-Early Venous Thromboembolism (VTE) Prophylaxis in Spontaneous Intracerebral Hemorrhage (sICH).

OBJECTIVE: To determine if ultra-early (<24 h) venous thromboembolism (VTE) prophylaxis was associated with hematoma growth in spontaneous intracerebral hemorrhage (ICH). BACKGROUND: Patients with ICH have a high risk of VTE. Pharmacological prophylaxis such as unfractionated heparin (UFH) have been demonstrated to reduce VTE. However, published datasets exclude patients with recent ICH out of concern for hematoma enlargement. American Heart/Stroke Association guidelines recommend UFH 1-4 days after hematoma stabilization while the European Stroke Organization has no recommendations on when to begin UFH. Our institutional practice is to obtain stability CT scans at 6 to 24 h and to begin UFH following documented clinical and radiologic stability. We examined the impact of this practice on hematoma expansion. METHODS: We performed a retrospective cohort analysis of consecutive ICH patients treated at a single tertiary academic referral center in the US. Demographic and clinical characteristics were abstracted. ICH volume was measured via 3D volumetrics for a CT head done on admission, follow-up stability, and prior to discharge. The primary outcome was analyzed as ≥3 mL hematoma enlargement. Secondary outcomes include hematoma expansion of ≥6mL and ≥ 33%, length of stay (LOS), discharge disposition and mortality. RESULTS: A total of 163 ICH patients were analyzed. There were 58 (35.6%) patients in the ultra-early UFH group and UFH was initiated on average at 13.8 h from initial scan. There were 105 (64.6%) patients in the standard group who initiated UFH at an average of 46.6 h. The primary outcome of hematoma enlargement ≥3 mL was observed in 2/58(3.4%) patients with ultra-early initiation of UFH and in 7/105(6.7%) in the standard group (p=0.49). Secondary outcomes were not significant including hematoma expansion in the ultra-early group ≥ 6 mL 3/58 (5.2%) and ≥33% 7/58 (12.1%) (p=0.91, 0.61, respectively) as well as mortality or LOS. CONCLUSION: Venous thromboembolism prophylaxis started ultra-early (≤24 h) after ICH was not associated with hematoma expansion.

Arterial and venous strokes in the setting of COVID-19.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) is a global pandemic that causes flu-like symptoms. There is a growing body of evidence suggesting that both the central and peripheral nervous systems can be affected by SARS-CoV-2, including stroke. We present three cases of arterial ischemic strokes and one venous infarction from a cerebral venous sinus thrombosis in the setting of COVID-19 infection who otherwise had low risk factors for stroke. METHODS: We retrospectively reviewed patients presenting to a large tertiary care academic US hospital with stroke and who tested positive for COVID-19. Medical records were reviewed for demographics, imaging results and lab findings. RESULTS: There were 3 cases of arterial ischemic strokes and 1 case of venous stroke: 3 males and 1 female. The mean age was 55 (48-70) years. All arterial strokes presented with large vessel occlusions and had mechanical thrombectomy performed. Two cases presented with stroke despite being on full anticoagulation. CONCLUSIONS: It is important to recognize the neurological manifestations of COVID-19, especially ischemic stroke, either arterial or venous in nature. Hypercoagulability and the cytokine surge are perhaps the cause of ischemic stroke in these patients. Further studies are needed to understand the role of anticoagulation in these patients.

Correction to: 2019 Neurocritical Care Survey: Physician Compensation, Unit Staffing and Structure.

The original article had a typo in Table 2, the "N" for males and females should be switched. The corrected table is shown below.

Comparison of Outcomes of Severe Traumatic Brain Injury in 36,929 Patients Treated with or without Intracranial Pressure Monitoring in a Mature Trauma System.

BACKGROUND: Severe traumatic brain injury (TBI) remains a major cause of morbidity and mortality with mortality rates reaching 35%. Intracranial pressure (ICP) monitoring is used to prevent secondary brain injury and death. However, while the association of elevated ICP and worsened outcomes is accepted, routine ICP monitoring has been questioned after the publication of several studies including the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure trial. We examined whether severe TBI patients in the trauma system of Pennsylvania fared better with or without ICP monitoring. METHODS: We conducted a statewide retrospective analysis and included all TBI patients >18 years with an admission Glasgow Coma Scale (GCS) <9 from January 2000 through December 2017. The primary outcome was mortality. Secondary outcomes examined were intensive care unit length of stay (LOS) and discharge functional independence measure (FIM). RESULTS: A total of 36,929 patients matched our inclusion criteria and were included in the analysis. Of those, 6025 (16.3%) had ICP monitor placement. Mean ICU LOS was significantly higher in ICP-monitored patients (13.1 ± 11.6 days vs. 6.0 ± 10.8 days, P < 0.0001). Increasing age was a significant predictor of death (P < 0.0001). Mean FIM scores at discharge were significantly higher in patients without an ICP monitor (16.21 ± 4.91 vs. 9.53 ± 5.07, P < 0.0001). When controlling for injury severity score, GCS, age, and craniotomy, ICP monitoring conferred a hazard ratio of 0.85 (χ2 = 32.63, P < 0.0001), a 25% reduction of in-hospital mortality compared with non-ICP-monitored patients. CONCLUSION: We found that ICP-monitored patients had a lower risk of in-hospital mortality. Our findings support the use of ICP monitors in eligible patients.

Statewide Trends in Intracranial Pressure Monitor Use in 36,915 Patients with Severe Traumatic Brain Injury in a Mature Trauma System over the Past 18 Years.

OBJECTIVE: Intracranial pressure (ICP)-guided therapy has been the mainstay of treatment of patients with severe traumatic brain injury (TBI), but recent data have questioned its efficacy. The aim of this study was to demonstrate trends in compliance to TBI guidelines and use of ICP-guided care in a mature trauma system. METHODS: A retrospective analysis was conducted of 36,915 patients with severe TBI collected by the Pennsylvania Trauma Systems Foundation. The registry includes all patients >18 years old with a diagnosis of TBI with a Glasgow Coma Scale score ≤8 who were admitted from January 2000 to December 2017. RESULTS: Of 36,915 patients, 73.6% were men with a median age of 43.0 ± 21.3 years. An ICP monitor was placed in 16.3% of all patients. The rate of ICP monitoring ranged from 17.8% of patients in 2000-2004 to 16.7% in 2005-2009, 16.4% in 2010-2014, and 12.8% in 2015-2017 (P < 0.001). The most statistically significant decrease was noted from 2014 (16.4%) to 2015 (14.1%, P = 0.042). The percent decrease in ICP monitoring from 2000-2014 to 2015-2017 was equivalent for patients with Glasgow Coma Scale scores of 3-5 (-4.0%) and 6-8 (-4.5%). CONCLUSIONS: As studies emerged that demonstrated unclear benefit of ICP monitoring in improving care in patients with severe TBI, there was a significant statewide decline in the use of ICP monitoring after 2014 among all TBI subpopulations despite noteworthy limitations in the aforementioned studies and clear recommendations from the Brain Trauma Foundation guidelines.

Analysis of the utility of early MRI/MRA in 400 patients with spontaneous intracerebral hemorrhage.

OBJECTIVE: MRI and MRA studies are routinely obtained to identify the etiology of intracerebral hemorrhage (ICH). The diagnostic yield of MRI/MRA in the setting of an acute ICH, however, remains unclear. The authors' goal was to determine the utility of early MRI/MRA in detecting underlying structural lesions in ICH and to identify patients in whom additional imaging during hospitalization could safely be foregone. METHODS: The authors reviewed data obtained in 400 patients with spontaneous ICH diagnosed on noncontrast head CT scans who underwent MRI/MRA between 2015 and 2017 at their institution. MRI/MRA studies were reviewed to identify underlying lesions, such as arteriovenous malformations, aneurysms, cavernous malformations, arteriovenous fistulas, tumors, sinus thrombosis, moyamoya disease, and abscesses. RESULTS: The median patient age was 65 ± 15.8 years. Hypertension was the most common (72%) comorbidity. Structural abnormalities were detected on MRI/MRA in 12.5% of patients. Structural lesions were seen in 5.7% of patients with basal ganglia/thalamic ICH, 14.1% of those with lobar ICH, 20.4% of those with cerebellar ICH, and 27.8% of those with brainstem ICH. Notably, the diagnostic yield of MRI/MRA was 0% in patients > 65 years with a basal ganglia/thalamic hemorrhage and 0% in those > 85 years with any ICH location, whereas it was 37% in patients < 50 years and 23% in those < 65 years. Multivariate analysis showed that decreasing age, absence of hypertension, and non-basal ganglia/thalamic location were predictors of finding an underlying lesion. CONCLUSIONS: The yield of MRI/MRA in ICH is highly variable, depending on patient age and hemorrhage location. The findings of this study do not support obtaining early MRI/MRA studies in patients ≥ 65 years with basal ganglia/thalamic ICH or in any ICH patients ≥ 85 years. In all other situations, early MRI/MRA remains valuable in ruling out underlying lesions.

Neurological Critical Care Services' Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization.

INTRODUCTION: Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI. METHODS: Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05. RESULTS: Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02).Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively.The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients. CONCLUSION: The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.

Early Ambulation in Patients With External Ventricular Drains: Results of a Quality Improvement Project.

INTRODUCTION: Prolonged immobility in patients in the intensive care unit (ICU) can lead to muscle wasting and weakness, longer hospital stays, increased number of days in restraints, and hospital-acquired infections. Increasing evidence demonstrates the safety and feasibility of early mobilization in the ICU. However, there is a lack of evidence in the safety and feasibility of mobilizing patients with external ventricular drains (EVDs). The purpose of this study was to determine the safety and feasibility of early mobility in this patient population. METHODS: We conducted a prospective, observational study. All patients in the study were managed with standard protocols and procedures practiced in our ICU including early mobility. Patients with an EVD who received early mobilization were awake and following commands, had a Lindegaard ratio <3.0 or middle cerebral artery (MCA) mean flow velocity <120 cm/s, a Mean Arterial Pressure (MAP) > 80 mm Hg, and an intracranial pressure consistently <20 mm Hg. Data were collected by physical therapists at the time of encounter. RESULTS: Ninety patients with a total of 185 patient encounters were recorded over a 12-month period. The average time between EVD placement and physical therapy (PT) session was 8.3 ± 5.5 days. In 149 (81%) encounters, patients were at least standing or better. Patients were walking with assistance or better in 99 (54%) encounters. There were 4 (2.2%) adverse events recorded during the entire study. CONCLUSION: This observational study suggests that PT is feasible in patients with EVDs and can be safely tolerated. Further research is warranted in a larger patient population conducted prospectively to assess the potential benefit of early mobility in this patient population.

Early Mobilization in the Neuro-ICU: How Far Can We Go?

Immobility that is frequently encountered in the intensive care unit (ICU) can lead to patient complications. Early mobilization of patients in the ICU has been shown to reduce the complications associated with critical illness; however, early mobilization in the neurological intensive care unit (NICU) presents a unique challenge for the multidisciplinary team. The early mobilization of patients with acute neurologic injuries such as acute ischemic stroke, aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, and neurotrauma varies because of differing disease processes and management. When developing an early mobility program in the NICU, the following should be considered: the effect of positional changes and exercise, the time from symptom onset to the initiation of early mobilization, and the type and intensity of the exercise prescribed.

Decompressive Hemicraniectomy in Acute Neurological Diseases.

Increased intracranial pressure (ICP) secondary to severe brain injury is common. Increased ICP is commonly encountered in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage. Multiple interventions-both medical and surgical-exist to manage increased ICP. Medical management is used as first-line therapy; however, it is not always effective and is associated with significant risks. Decompressive hemicraniectomy is a surgical option to reduce ICP, increase cerebral compliance, and increase cerebral blood perfusion when medical management becomes insufficient. The purpose of this review is to provide an up-to-date summary of the use of decompressive hemicraniectomy for the management of refractory elevated ICP in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage.

Asymptomatic central pontine myelinolysis: a case report.

INTRODUCTION: Central pontine myelinolysis (CPM) is an acquired demyelinating lesion of the basis pontis that typically occurs after rapid correction of hyponatremia. There are only a few reported cases of patients without symptoms that have demonstrated CPM on imaging. CASE PRESENTATION: We report the case of a 26-year-old Hispanic male with history of alcohol abuse who was transferred to our medical center for acute onset diffuse abdominal pain. During his work up, a computed tomography scan demonstrated a large pancreatic mass. He underwent an endoscopic guided biopsy which demonstrated a rare and aggressive natural killer T cell lymphoma. His laboratory values were consistent with hyponatremia, which the medical team gently corrected. An MRI was performed for staging purposes which revealed findings consistent with CPM. A full neurological exam demonstrated no deficits. MATERIALS AND METHODS: WE CONDUCTED A PUBMED SEARCH USING THE FOLLOWING KEYWORDS: asymptomatic, central, pontine, and myelinolysis in order to find other case reports of asymptomatic CPM. RESULTS: Of the 29 results, only 6 previous case reports with English language abstracts of asymptomatic CPM were present since 1995. CONCLUSION: Despite slow correction of hyponatremia, CPM can be an important consequence, especially in patients with chronic alcoholism. Although this patient did not demonstrate any neurological deficits, the fact that there were changes seen on MRI should caution physicians in aggressively treating hyponatremia. Furthermore, if there is a decision to treat, then fluid restriction and reversal of precipitating factors (i.e. diuretics) should be used initially, unless there is concern for hypovolemia.

Late-onset neurodegeneration with brain iron accumulation with diffusion tensor magnetic resonance imaging.

INTRODUCTION: Neuroferritinopathy is an autosomal dominant neurodegenerative disorder that includes a movement disorder, cognitive decline, and characteristic findings on brain magnetic resonance imaging (MRI) due to abnormal iron deposition. Here, we present a late-onset case, along with diffusion tensor imaging (DTI). CASE PRESENTATION: We report the case of a 74-year-old Caucasian female with no significant past medical history who presented for evaluation of orofacial dyskinesia, suspected to be edentulous dyskinesia given her history of ill-fitting dentures. She had also developed slowly progressive dysarthria, dysphagia, visual hallucinations as well as stereotypic movements of her hands and feet. RESULTS: The eye-of-the-tiger sign was demonstrated on T2 MRI. Increased fractional anisotropy and T2 hypointensity were observed in the periphery of the globus pallidus, putamen, substantia nigra, and dentate nucleus. T2 hyperintensity was present in the medial dentate nucleus and central globus pallidus. DISCUSSION: The pallidal MRI findings were more typical of pantothenate kinase-associated neurodegeneration (PKAN), but given additional dentate and putamenal involvement, lack of retinopathy, and advanced age of onset, PKAN was less likely. Although the patient's ferritin levels were within low normal range, her clinical and imaging features led to a diagnosis of neuroferritinopathy. CONCLUSION: Neurodegeneration with brain iron accumulation (NBIA) is a rare cause of orofacial dyskinesia. DTI MRI can confirm abnormal iron deposition. The location of abnormal iron deposits helps in differentiating NBIA subtypes. Degeneration of the dentate and globus pallidus may occur via an analogous process given their similar T2 and DTI MRI appearance.