Rajkumar Agarwal

Management of Pediatric Migraine in a Tertiary Care Versus Community Based Emergency Department: An Observational Pilot Study

BACKGROUND Because of a lack of guidelines for the management of pediatric migraine in the emergency department setting, marked variations in treatment protocols exist between institutions. We aimed to characterize differences in management strategies for pediatric migraine treatment between a community-based and a tertiary care emergency department. METHODS A retrospective cohort study was performed to include pediatric patients presenting with headache fulfilling the International Classification of Headache Disorders-2 migraine criteria in a tertiary care (site 1) and a community based (site 2) emergency department. The two sites were compared with respect to patient demographics and approach to treatment. RESULTS A total of 158 patients at site 1 (mean age 13.6 years, 70% female, 68% African-American) and 63 patients at site 2 (mean age 16.7 years, 71% female, 100% Caucasian) were analyzed. Opiate use (7.6% vs. 33%), imaging (6.3% vs. 20.6%), use of nonsteroidal anti-inflammatory drugs/serotonin agonists at discharge (72.7% vs. 22.2%), and admission rates to hospital (22% vs. 0%) were significantly different. Logistic regression analysis indicated that the main predictors of hospital admission were use of opiates and intravenous combination abortive therapy. CONCLUSION Low rates of intravenous combination therapy, antidopaminergic agent, and serotonin agonist use were noted across both hospital settings. Community-based physicians used opiates and obtained neuro-imaging more than those in the academic setting. Standardization of care in the emergency setting coupled with reliable acute care plans that are based on evidenced-based guidelines can allow for better control of episodic migraine and reduce emergency department visits.

Posterior Reversible Encephalopathy and Cerebral Vasoconstriction in a Patient With Hemolytic Uremic Syndrome

BACKGROUND We report a patient with hemolytic uremic syndrome who presented with radiological manifestations suggestive of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome. PATIENT A 13-year-old girl presented with fever and bloody diarrhea and progressed to develop hemolytic uremic syndrome. She subsequently developed encephalopathy, aphasia, and right-sided weakness. RESULTS Brain magnetic resonance imaging showed presence of vasogenic edema in the left frontal lobe, in addition to T2 and fluid-attenuated inversion recovery changes in white matter bilaterally, compatible with posterior reversible encephalopathy syndrome. Magnetic resonance angiography showed beading of the cerebral vessels. Neurological deficits reversed 8 days after symptom onset, with resolution of the beading pattern on follow-up magnetic resonance angiography after 3 weeks, suggesting reversible cerebral vasoconstriction syndrome. CONCLUSIONS Both posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome may represent manifestations of similar underlying pathophysiologic mechanisms. Recognition of the co-existence of these processes in patients with hemolytic uremic syndrome may aid in judicious management of these patients and avoidance of inappropriate therapeutic interventions.

Thalamic abnormalities in children with continuous spike-wave during slow-wave sleep: An F-18-fluorodeoxyglucose positron emission tomography perspective.

Thalamic injury has been implicated in the development of continuous spike‐wave during slow‐wave sleep (CSWS) in children with epilepsy. We studied thalamic abnormalities in children with CSWS using F‐18‐fluorodeoxyglucose (FDG)–positron emission tomography (PET) imaging.

Episodic Headache and Arachnoid Cyst Related Subdural Hematoma.

A 7-year-old boy presented with a 1-month history of episodic bifrontal throbbing headache associated with photophobia, bilateral painful arm paresthesias, and intense agitation. Symptoms developed 2 weeks after a trivial trampoline fall causing blunt head trauma without loss of consciousness. Three interval emergency room visits led to transient improvement with intravenous analgesics. During this (fourth) visit, additional symptoms included binocular diplopia. Examination showed excessive irritability but was negative for focal neurological signs or obvious eye movement abnormalities. A brain magnetic resonance imaging (MRI) completed during this encounter showed bilateral arachnoid cysts with hemorrhage and evidence of transtentorial herniation (Fig. 1). Surgical evacuation of hematomas resulted in dramatic recovery. Chronic subdural hematoma (CSDH) is a rare complication of an arachnoid cyst reported in children as young as 3 years. Although the pathogenesis is contentious, CSDH may occur due to a trivial or an unrecognized trauma. Patients may present with worsening headache and focal neurological deficits due to elevated intracranial pressure. Migraine-like headaches, likely related to cortical spreading depression triggered by the CSDH, have also been described. The presence of irritability, diplopia, and recent head trauma constitute “red flags” in a child with new onset headache and should warrant further investigation.

Ictal motor sequences: Lateralization and localization values.

To determine the lateralization and localization values of ictal motor sequences in the setting of focal epilepsy ending with a secondarily generalized motor seizure.

Presurgical language mapping using event-related high-gamma activity: The Detroit procedure

A number of investigators have reported that event-related augmentation of high-gamma activity at 70-110 Hz on electrocorticography (ECoG) can localize functionally-important brain regions in children and adults who undergo epilepsy surgery. The advantages of ECoG-based language mapping over the gold-standard stimulation include: (i) lack of stimulation-induced seizures, (ii) better sensitivity of localization of language areas in young children, and (iii) shorter patient participant time. Despite its potential utility, ECoG-based language mapping is far less commonly practiced than stimulation mapping. Here, we have provided video presentations to explain, point-by-point, our own hardware setting and time-frequency analysis procedures. We also have provided standardized auditory stimuli, in multiple languages, ready to be used for ECoG-based language mapping. Finally, we discussed the technical aspects of ECoG-based mapping, including its pitfalls, to facilitate appropriate interpretation of the data.

Safety, Awareness, and Familiarity regarding Epilepsy in Teenage Years (SAFETY): Understanding the adolescents' perspective about their disease

OBJECTIVE The objective of this study was to evaluate the understanding of adolescent patients regarding epilepsy. METHODS The SAFETY (Safety, Awareness, and Familiarity regarding Epilepsy in Teenage Years) questionnaire (content validity index: 0.96, Flesch readability score: 66.6) was administered to 165 cognitively normal adolescents with epilepsy (85 females, mean age: 15.2 ± 1.6 years, range: 13-18 years). The first part of the questionnaire was devised to evaluate knowledge about epilepsy and antiepileptic medications (SAFETY-K: 7 questions). The second part queried lifestyle modifications and safety (SAFETY-S: 10 questions). Female participants answered 5 additional questions related to reproductive health (RH questionnaire). RESULTS The correct response rate for the composite SAFETY questionnaire was 51.5%. The average rates of correct responses for the SAFETY-K and SAFETY-S questions were 47.9% and 53.9%, respectively. On univariate logistic regression analysis, factors which were significant predictors of correct responses included age (odds ratio: 1.8, C.I. = 1.3-2.4), race (Caucasian vs. African-American; odds ratio: 3.9, C.I. = 1.4-10.4), and employment of at least one parent in a professional occupation (odds ratio: 3.3, C.I. = 1.1-10.3). The correct response rate did not correlate with the duration of epilepsy, extent of seizure control, number of antiepileptic medications, parental educational, or (un)employment status. The mean rate of correct responses for the RH questions amongst teenage girls was 17.4%. CONCLUSIONS There is lack of awareness about epilepsy and its associated lifestyle modifications in adolescents with epilepsy seen at our institution. This is especially true in young adolescents, African-American patients, and those whose parents are not employed in professional occupations. Teenage girls with epilepsy appear to have limited knowledge with respect to contraception and childbearing.

Is Shunt Evaluation Useful in Children with Intraventricular Shunts with Seizures

BACKGROUND Seizures are a common presenting symptom to the emergency department (ED) in children with intraventricular shunts (IVS). The incidence of shunt malfunction and the yield of imaging studies in children with IVS presenting with seizures is unknown. OBJECTIVES We assessed the utility and diagnostic yield of evaluation for shunt malfunction in patients with IVS with seizure and identified clinical predictors for shunt malfunction in these children. METHODS We performed a retrospective review of children aged zero to 21 years of age with IVS who presented to the ED with seizure between 2011 and 2015. Demographic, clinical, laboratory and radiological data were collected. Shunt malfunction was diagnosed based on whether a shunt revision was performed during the hospitalization. RESULTS We evaluated 408 ED visits (median age: six years [IQR: 3, 11], males 61.5%) for IVS with seizures. Few visits were for first seizure (37; 9.1%) or for status epilepticus (46 visits; 11.3%). Computerized tomography head was performed in 318 patients (95.2%), of which 32 scans (10.6%) were suggestive of shunt malfunction. A shunt series was performed in 302 (90.4%) and was suggestive of shunt malfunction in eight (2.6%) patients. Shunt malfunction was diagnosed in 40 of 408 visits (9.8%). Only a history of multiple (≥3) shunt revisions was significantly associated with shunt malfunction. There was no association between number, type, or prior history of seizures and shunt malfunction. CONCLUSION Our study demonstrates a low yield of imaging studies for the evaluation of shunt malfunction in children with IVS with seizures, and shunt malfunction is an uncommon cause of seizures in these children.

Phase-amplitude coupling between interictal high-frequency activity and slow waves in epilepsy surgery

We hypothesized that the modulation index (MI), a summary measure of the strength of phase‐amplitude coupling between high‐frequency activity (>150 Hz) and the phase of slow waves (3‐4 Hz), would serve as a useful interictal biomarker for epilepsy presurgical evaluation.

More than meets the eye: infant presenting with hypoxic ischaemic encephalopathy

We report a newborn infant who presented with poor Apgar scores and umbilical artery acidosis leading to the diagnosis of hypoxic ischaemic encephalopathy. During the course of the infant’s hospitalisation, subsequent workup revealed an underlying genetic cause that masqueraded as hypoxic ischaemic encephalopathy.