Elizabeth Mauricio

Status epilepticus in the elderly: Differential diagnosis and treatment

Seizures are not an uncommon occurrence in older adults, and the incidence of status epilepticus is much greater in the elderly than in younger populations. Status epilepticus is a neurologic emergency and requires prompt intervention to minimize morbidity and mortality. Treatment involves both supportive care as well as initiation of medications to stop all clinical and electrographic seizure activity. Benzodiazepines are used as first-line agents, followed by antiepileptic drugs when seizures persist. In refractory status epilepticus, urgent neurologic consultation is indicated for the titration of anesthetic agents to a level of appropriate background suppression on EEG. In light of our aging population, physician awareness and competence in the management of status epilepticus is imperative and should be recognized as a growing public health concern.

Ambulance-based assessment of NIH Stroke Scale with telemedicine: A feasibility pilot study

Background Ischemic stroke is a time-sensitive disease, with improved outcomes associated with decreased time from onset to treatment. It was hypothesised that ambulance-based assessment of the National Institutes of Health Stroke Scale (NIHSS) using a Health Insurance Portability and Accountability Act (HIPAA)–compliant mobile platform immediately prior to arrival is feasible. Methods This is a proof-of-concept feasibility pilot study in two phases. The first phase consisted of an ambulance-equipped HIPAA-compliant video platform for remote NIHSS assessment of a simulated stroke patient. The second phase consisted of remote NIHSS assessment by a hospital-based neurologist of acute stroke patients en route to our facility. Five ambulances were equipped with a 4G/LTE-enabled tablet preloaded with a secure HIPAA-compliant telemedicine application. Secondary outcomes assessed satisfaction of staff with the remote platform. Results Phase one was successful in the assessment of three out of three simulated patients. Phase two was successful in the assessment of 10 out of 11 (91%) cases. One video attempt was unsuccessful because local LTE was turned off on the device. The video signal was dropped transiently due to weather, which delayed NIHSS assessment in one case. Average NIHSS assessment time was 7.6 minutes (range 3–9.8 minutes). Neurologists rated 83% of encounters as ‘satisfied’ to ‘very satisfied’, and the emergency medical service (EMS) rated 90% of encounters as ‘satisfied’ to ‘very satisfied’. The one failed video attempt was associated with ‘poor’ EMS satisfaction. Conclusion This proof-of-concept pilot demonstrates that remote ambulance-based NIHSS assessment is feasible. This model could reduce door-to-needle times by conducting prehospital data collection.

Improving referring physicians' understanding of electromyography reports when qualifying radiculopathies: A need for standardized terminology

Electromyographic (EMG) reporting of radiculopathies is not standardized, and the terminology used in reports can be misinterpreted by referring physicians. Physicians who refer patients for EMG studies at the Mayo Clinic were surveyed about their understanding of 6 different EMG interpretations of an S1 radiculopathy. Of 45 responders, the terms “acute, active,” “chronic, inactive,” and “old” were interpreted consistently by 95%, 98%, and 84% of responders, respectively. Physicians had the most difficulty understanding the meaning of “chronic” in isolation, “chronic, active,” or “old with uncompensated denervation.” These findings suggest a need to educate referring physicians on the meaning of the terms used in EMG reports and to develop standard guidelines for qualifying radiculopathies. Based on our observations, guidelines for the reporting of radiculopathies have been adopted in the Mayo Clinic Florida EMG laboratory. Muscle Nerve 49: 129–130, 2014

Utility of minimum F-wave latencies compared with F-estimates and absolute reference values in S1 radiculopathies: are they still needed?

Introduction: The utility of F‐waves in assessing radiculopathies is debated. The aim of this study is to determine the frequency of abnormal minimum tibial F‐wave latencies compared to an F‐estimate and an absolute reference value in patients with electromyography (EMG) confirmed S1 radiculopathies. Methods: A retrospective review of F‐waves in patients with an EMG‐confirmed isolated S1 radiculopathy was performed. The minimum and mean latencies of 8 tibial F‐waves were compared with the calculated F‐estimate and to an absolute reference value, and the frequencies of abnormal responses were determined. Results: Of the 50 patients with an S1 radiculopathy, 4% had prolongation of the minimum reproducible F‐wave latency, and 8% had prolongation of the mean latency relative to the calculated F‐estimate. Conclusions: The minimum and mean F‐wave latencies are infrequently abnormal when compared with an estimated F‐wave latency in S1 radiculopathies and are insensitive in the assessment of S1 nerve root injury. Muscle Nerve 49: 809–813, 2014

New antiepileptic drugs: focus on ezogabine, clobazam, and perampanel.

Ezogabine, clobazam, and perampanel are among the newest antiseizure drugs approved by the Food and Drug Administration between 2011 and 2012. Ezogabine and perampanel are approved for adjunctive treatment of partial epilepsy. Perampanel is also approved for adjunctive treatment of primary generalized tonic–clonic seizures. Ezogabine and perampanel have novel mechanisms of action. Ezogabine binds to voltage-gated potassium channels and increases the M-current thereby causing membrane hyperpolarization. Perampanel is a selective, non-competitive 2-amino-3-(3-hydroxy-5-methyl-isoxazol-4-yl)propanoic acid receptor antagonist, which reduces neuronal excitation. Clobazam has been used worldwide since the 1970s and is approved for adjunctive treatment of seizures associated with Lennox-Gastaut syndrome. Clobazam is the only 1,5-benzodiazepine currently in clinical use, which is less sedating than the commonly used 1,4-benzodiazepines. Phase III multicenter, randomized, double-blind, placebo-controlled trials demonstrated efficacy and good tolerability of these 3 new antiepileptic drugs. These drugs represent a welcome addition to the armamentarium of practitioners, but it remains to be seen how they will affect the landscape of pharmacoresistant epilepsy.