Sanjeev Sivakumar

Clobazam: An effective add‐on therapy in refractory status epilepticus

Refractory status epilepticus (RSE) is a medical emergency, with significant morbidity and mortality. The use and effectiveness of clobazam, a unique 1,5‐benzodiazepine, in the management of RSE has not been reported before. Over the last 24 months, we identified 17 patients with RSE who were treated with clobazam in our hospital. Eleven of the 17 patients had prior epilepsy. Fifteen patients had focal status epilepticus. Use of clobazam was prompted by a favorable pharmacokinetic profile devoid of drug interactions. Clobazam was introduced after a median duration of 4 days and after a median of three failed antiepileptic drugs. A successful response, defined as termination of RSE within 24 h of administration, without addition or modification of concurrent AED and with successful wean of anesthetic infusions, was seen in 13 patients. Indeterminate response was seen in three patients, whereas clobazam was unsuccessful in one patient. Clobazam averted the need for anesthetic infusions in five patients. Clobazam was well tolerated, and appears to be an effective and promising option as add‐on therapy in RSE. Its efficacy, particularly early in the course of SE, should be further investigated in prospective, randomized trials.

A retrospective cross-sectional study of the prevalence of generalized convulsive status epilepticus in traumatic brain injury: United States 2002–2010

PURPOSE To determine the incidence, predictors, and outcomes of generalized convulsive status epilepticus (GCSE) in traumatic brain injury (TBI) patients. METHODS We conducted a retrospective cross-sectional study of adult patients with acute TBI using the 2002-2010 Nationwide Inpatient Sample (NIS) database of USA. We used multivariable logistic regression analyses to identify independent predictors of GCSE in patients with TBI and to determine the impact of GCSE on outcomes (in-hospital mortality, length of stay, total hospital charges, and discharge disposition). RESULTS Among 1,457,869 patients hospitalized with TBI, 2315 (0.16%) had GCSE. In-hospital mortality was significantly higher in patients with GCSE (32.5% vs. 9.6%; unadjusted OR 4.54, 95% CI 4.16-4.96; p<0.001; adjusted OR 3.41; 95% CI 3.09-3.76 p<0.001). Patients with GCSE had longer length of stay (17.3 ± 21.9 vs. 6.8 ± 11.1 days; p<0.001), higher total hospital charges (

Cerebral Pathophysiology in Extracorporeal Membrane Oxygenation: Pitfalls in Daily Clinical Management

147,415 ± 162,319 vs.

Mystery Case: CNS posttransplant lymphoproliferative disorder

54,041 ± 90,524; p<0.001), and were less likely to be discharged home (19.8% vs. 52.7%; p<0.001). Using multivariable logistic regression analysis, age >35 years (OR 2.15; 95% CI 1.87-2.47), CNS infections (OR 4.86; 95% CI 3.70-6.38), anoxic brain injury (OR 9.54; 95% CI 8.10-11.22), and acute ischemic stroke (OR 4.09; 95% CI 3.41-4.87) were independent predictors of GCSE in TBI patients. Epilepsy was an independent negative predictor of GCSE (OR 0.74; 95% CI 0.55-0.99). CONCLUSION Despite its low incidence, GCSE in TBI patients was associated with worse outcomes with threefold higher in-hospital mortality, prolonged hospitalization, higher hospital charges, and worse discharge disposition. Surprisingly, epilepsy is a negative predictor of GCSE in this population.

Hemodynamic and neuro-monitoring for neurocritically ill patients: An international survey of intensivists

Extracorporeal membrane oxygenation (ECMO) is a life-saving technique that is widely being used in centers throughout the world. However, there is a paucity of literature surrounding the mechanisms affecting cerebral physiology while on ECMO. Studies have shown alterations in cerebral blood flow characteristics and subsequently autoregulation. Furthermore, the mechanical aspects of the ECMO circuit itself may affect cerebral circulation. The nature of these physiological/pathophysiological changes can lead to profound neurological complications. This review aims at describing the changes to normal cerebral autoregulation during ECMO, illustrating the various neuromonitoring tools available to assess markers of cerebral autoregulation, and finally discussing potential neurological complications that are associated with ECMO.

Effects of Marijuana on Ictal and Interictal EEG Activities in Idiopathic Generalized Epilepsy

A 74-year-old right-handed Hispanic woman with history of renal transplant 19 years prior presented at an away institution with episodic confusion and gait ataxia progressing over 2 weeks. She was alert and oriented on initial presentation but with fluctuation in mental status and without obvious cranial nerve, motor, or sensory deficits. The patient received transplant immunosuppression therapy with mycophenolate mofetil (Cellcept; Roche, Basel, Switzerland) and had a history of hypertension and chronic kidney disease. CT of the head showed a hypodense lesion in the right temporal lobe. MRI of the brain demonstrated multifocal, infiltrative T2-hyperintense white matter lesions involving the right temporo-parietal region, right frontal lobe, left parietal lobe, and left thalamus (figure, A–C). Gadolinium was not administered due to renal dysfunction. Lumbar puncture (LP) showed 63 leukocytes with lymphocytic pleocytosis (88%), elevated protein (80 mg/dL), and normal glucose (71 mg/dL). CSF Gram stain and culture were negative. She was treated with corticosteroids and acyclovir for presumed autoimmune/demyelinating vs infectious etiologies. She developed multiple witnessed periods of behavioral arrest with eye blinking and confusion concerning for seizures. She was transferred to our institution.

Monocular Blindness as Presentation Manifestation of Neuroblastoma.

Purpose: To investigate multimodality systemic and neuro‐monitoring practices in acute brain injury (ABI) and to analyze differences among “neurointensivists” (NI; clinical practice comprised >1/3 by neurocritical care), and other intensivists (OI). Methods: Anonymous 22‐question Web‐based survey among physician members of SCCM and ESICM. Results: Six hundred fifty‐five responded (66% completion rate); 422 (65%) were OI, and 226 (35%) were NI. More NI follow hemodynamic protocols for TBI (44.5% vs 33%, P = .007) and SAH (38% vs 21%, P < .001). For CPP optimization, NI use more arterial‐waveform‐analysis (AWA) (45% vs 35%, P = .019), and ultrasound (37.5% vs 28%, P = .023); NI use more PbtO2 (28% vs 10%, P < .001). In the case scenario of raised ICP/low PbtO2, most employ analgesia and/or sedation (47%) and osmotherapy (38%). More NI use pressure reactivity (vasopressor use OI 23% vs NI 34.5%, P = .014). For DCI, more NI target cardiac index (CI) (35% vs 21%, P < .001), and fluid responsiveness (62.5% vs 53%, P = .03). Also, NI use more angiography (57% vs 43.5%, P = .004), TCD (56.5% vs 38%, P < .001), CTP (32% vs16%, P < .001), and PbtO2 (18% vs 7.5%, P = .001). Conclusions: Intensivists with exposure to ABI patients employ more neuro‐ and hemodynamic monitoring. We found large heterogeneity and low overall use of advanced brain‐physiology parameters. HighlightsThe overall use of multimodality neuromonitoring is low.Physicians make limited efforts to individualize physiological targets.Intensivists with exposure to acute brain injury tend to employ more monitoring.Further research is needed to define the practical utility of these parameters.

IMAGES IN CLINICAL MEDICINE. Secondary Palatal Myoclonus.

Summary: Marijuana-based treatment for refractory epilepsy shows promise in surveys, case series, and clinical trials. However, literature on their EEG effects is sparse. Our objective is to analyze the effect of marijuana on EEG in a 24-year-old patient with idiopathic generalized epilepsy treated with cannabis. We blindly reviewed 3 long-term EEGs—a 24-hour study while only on antiepileptic drugs, a 72-hour EEG with Cannabis indica smoked on days 1 and 3 in addition to antiepileptic drugs, and a 48-hour EEG with combination C indica/sativa smoked on day 1 plus antiepileptic drugs. Generalized spike–wave discharges and diffuse paroxysmal fast activity were categorized as interictal and ictal, based on duration of less than 10 seconds or greater, respectively. Data from three studies concatenated into contiguous time series, with usage of marijuana modeled as time-dependent discrete variable while interictal and ictal events constituted dependent variables. Analysis of variance as initial test for significance followed by time series analysis using Generalized Autoregressive Conditional Heteroscedasticity model was performed. Statistical significance for lower interictal events (analysis of variance P = 0.001) was seen during C indica use, but not for C indica/sativa mixture (P = 0.629) or ictal events (P = 0.087). However, time series analysis revealed a significant inverse correlation between marijuana use, with interictal (P < 0.0004) and ictal (P = 0.002) event rates. Using a novel approach to EEG data, we demonstrate a decrease in interictal and ictal electrographic events during marijuana use. Larger samples of patients and EEG, with standardized cannabinoid formulation and dosing, are needed to validate our findings.

Electroencephalographic Observations of Medical Marijuana for Idiopathic Generalized Epilepsy: A Case Report (P6.368)

A previously healthy 4-year-old patient was admitted with a 2-week history of extreme irritability with no apparent etiology on initial examination. Coincidentally, the child was noted to have intermittent strabismus involving the right eye. His visual acuity was 20/200 on the affected side with an afferent pupillary defect. On dilated direct ophthalmoscopy, a swollen optic disc was noted. There was no restriction of ocular movements. Magnetic resonance imaging of the brain and the orbits revealed a large, lobulated, contrast-enhancing mass in the region of the sphenoid bone (Figure 1A). The right optic nerve appeared to be completely surrounded by the mass (accounting for the edema of the optic disc on examination). Figure 1. A, 3.0T Magnetic resonance imaging of the brain and orbits. T1-weighted postcontrast image demonstrating an enhancing mass in the region of the sphenoid bone with involvement of the sphenoid sinuses and posterior ethmoid air cells. The mass involves the ... Meta-iodobenzylguanidine (MIBG) scan (using iodine-123-MIBG) showed evidence of diffuse metastases in axial and appendicular bones. The primary lesion was identified as a neuroblastoma involving the left adrenal medulla. Biopsy of the adrenal mass revealed round blue cells with scant cytoplasm and scattered Homer-Wright rosettes suggestive of neuroblastoma (Figure 1B). Cytogenetics revealed amplification of the Neuroblastoma MYC Oncogene (NMYC), which correlates with increased frequency of intracranial or orbital, liver, and lung metastasis.1 Neuroblastoma—the most common extracranial solid tumor of childhood—consists of cells derived from the neural crest. Patients presenting with blindness often have stage IV disease. At the time of initial diagnosis, up to 18% of children will have metastases to the cranial bones/orbit.1 Neurologists who encounter optic disc swelling should entertain a broad differential diagnosis and consider early imaging to avoid potentially fatal pitfalls.

Clobazam as Add-on Therapy in Refractory Status Epilepticus (P5.085)

A 59-year-old woman with a history of diabetes, hypertension, and multiple previous strokes presented for evaluation. She had had acute onset of imbalance and difficulty speaking 2 years earlier. Examination revealed a constant, jerky movement of the soft palate, shown in a video.