Post-operative nonketotic hyperglycemic induced focal motor status epilepticus related to treatment with corticosteroids following standard anterior temporal lobectomy

•Complications from standard ATL are uncommon and the use of post-operative corticosteroids may reduce complications.•Following standard ATL, FMSE was present after treatment with corticosteroids that resolved after blood sugar control.•After epilepsy surgery, corticosteroids should be used cautiously in people with comorbid diabetes mellitus

The Effect of Botulinum Toxin on Network Connectivity in Cervical Dystonia: Lessons from Magnetoencephalography

Background: Pharmacological management of cervical dystonia (CD) is considered to be symptomatic in effect, rather than targeting the underlying pathophysiology of the disease. Magnetoencephalography (MEG), a direct measure of neuronal activity, while accepted as a modality for pre-surgical mapping in epilepsy, has never been used to explore the effect of pharmacotherapy in movement disorders. Methods: Resting state MEG data were collected from patients with CD, pre- and post-botulinum toxin injections. All of these patients exhibited good clinical benefit with botulinum toxin. Resting state MEG data from four age- and gender-matched healthy controls with no neurological disorders were also collected. Results: Our exploratory study reveals a difference in coherence between controls and patients in the following regions: fronto-striatal, occipito-striatal, parieto-striatal, and striato-temporal networks. In these regions there is an increase after botulinum toxin. Specifically, increased coherence in the left putamen and right superior parietal gyrus was noticeable. Both intrahemispheric and interhemispheric networks were affected. Discussion: This is the first attempt to directly assess changes in functional connectivity with pharmacotherapy using MEG. Botulinum toxin might affect sensorimotor integration, leading to clinical benefit. The presence of increased interhemispheric coherence and intrahemispheric coherence points to the importance of global and local networks in the pathophysiology of dystonia

“What are the odds?”: A rare clinical syndrome from a rare vascular condition caused by a commonly used medication

Objective: Describe a case of a patient developing Balint\u27s syndrome from bilateral parieto-occiptal ischemic infarcts secondary to reversible cerebral vasoconstriction syndrome (RCVS) after sumatriptan use. Background: Sumatriptan is a commonly prescribed anti-migraine medication which has 5HT 1B & 1D agonistic properties. Injudicious use of sumatriptan can lead to intracranial vasoconstriction with disastrous outcomes as exemplified in our patient. Design/Methods: Case-study Results: 29-years old female with a remote history of headaches presented with severe headaches and acute encephalopathy. MRI revealed bilateral parieto-occipital infarcts. Autoimmune workup and cerebrospinal fluid analysis were unremarkable. Catheter angiography revealed moderate diffuse spasm of the basilar, bilateral intracranial internal carotid, and proximal middle cerebral arteries (MCA). Use of intra-arterial nicardipine during the angiography procedure was limited due to patient\u27s baseline hypotension. Verapamil was started along with fludrocortisone. Her progress was followed by serial transcranial-doppler which revealed resolution of MCA vasospasm. After clinical improvement with verapamil, she admitted taking 300-mg sumatriptan over a 5-day period prior to the onset of her encephalopathy. In addition, her neurological exam demonstrated clinical signs of optic ataxia and simultagnosia, consistent with Balint\u27s syndrome due to the location of the stroke Conclusions: On reviewing the literature, only two cases of RCVS have been reported with sumatriptan use. Our patient possesses a high educational value due to the presence of a rare clinical syndrome of Balint\u27s, from an unusual vascular pathology of RCVS, which was likely secondary from a medication with vasoconstrictive properties. RCVS commonly causes a “thunderclap” headache but in severe cases, can also be associated with ischemic or hemorrhagic infarction, encephalopathy, and seizures. Location of the ischemic infarcts in the bilateral parietal region enabled our patient to possess a mysterious clinical syndrome of simultagnosia and optic ataxia which was first described in 1909. The only sign missing in our patient from the classical Balint syndrome was ocular apraxia

MyChart enrollment and other factors that affect no show rates in the neurology resident clinic

Objective: To investigate how MyChart enrollment and other factors affect patient adherence to coming to their Neurology appointment in the Resident Clinic. Background: The waiting list for the Neurology Clinic at Henry Ford Hospital exceeds two months. Additionally, there are frequent “no-shows, especially in the Resident Clinic. This leads to wasted patient slots and prevents patients on the waitlist from being seen in an expedited manner. Those patients that have the MyChart software from EPIC Systems receive automatic reminders; however, it is unclear if this affects patient\u27s adherence rates. We sought to determine what impact MyChart enrollment, as well as other factors, have upon show rates. Design/Methods: Patients from October 2015, February 2016, and June 2016 scheduled in the Neurology Resident Clinic were selected. The following information was collected: date of scheduled clinic visit, if patient came to their appointment, enrollment in MyChart, gender, age, race, and method of referral to the clinic. Chi-squared tests were done to assess the association of appointment status (no show, showed and canceled) with demographic and visit information. Results: Patients with MyChart enrollment had significantly lower rates of no show (19% vs 27%) and higher rates of showed (59% vs 48%) compared to patients without MyChart enrollment. Younger patients (18-49) had the highest rates of no show (28%) while older patients (65+) had the lowest rates of no show (17%). Caucasian patients had significantly lower rates of no show compared to non-Caucasian patients (14% vs 24%). Non-English speaking patients had high rates of no show (34%). Patients with a physician referral had significantly lower rates of no show (20% vs 28%) and higher rates of showed (61% vs 44%) compared to patients with a self-referral. Conclusions: Our study indicates that the status of MyChart enrollment, age, race and physician referral have a significant impact upon no-show rates

Education Research: Electronic patient portal enrollment and no-show rates within a neurology resident clinic

OBJECTIVE: To identify factors that affect appointment adherence and investigate the association of electronic patient portal (ePP) enrollment and patient adherence rates to appointments in the Neurology Resident Clinic (NRC). METHODS: Patients scheduled for an appointment during the months of October 2015, February 2016, and June 2016 in the NRC were included. ePP enrollment, date of clinic appointment, method of referral to the clinic, and key demographic criteria were collected. χ RESULTS: Patients with ePP enrollment had significantly lower rates of no-show (19% vs 27%) and higher rates of showed (59% vs 48%) compared to patients without ePP enrollment. Younger patients (18-49) had the highest rates of no-show (28%), while older patients (65+) had the lowest rates of no-show (17%). Caucasian patients had significantly lower rates of no-show compared to non-Caucasian patients (14% vs 24%). Non-English-speaking patients had high rates of no-show (34%). Patients with a physician referral had significantly lower rates of no-show (20% vs 28%) and higher rates of showed (61% vs 44%) compared to patients with a self-referral. CONCLUSIONS: Our study indicates that ePP enrollment, age, race, and physician referral might be associated with reduced no-show rates in the NRC

Cervical dystonia and visual processing speed: Insights from magnetoencephalography

Background Patients with cervical dystonia (CD) have been found to have impaired working memory, processing speed, visual motor ability and short term memory. We aimed to investigate changes in cerebral oscillations at the network level during a visual processing speed test (executive function), pre-and-post administration of botulinum toxin, using MEG in CD patients. Methods MEG data was collected on 5 CD patients while performing a visual continuous performance task (CPT), a go-no-go test, pre-and-post botulinum toxin injection. Similar MEG data was also collected on 5 age and gender-matched controls. Coherence source imaging was performed to quantify executive function network connectivity of subjects. Results In controls, there were 2 errors with visual CPT, with CD patients demonstrating 6 and 3 errors pre-and-post botulinum toxin, respectively. Average time from visual cue to correct response was 0.337 seconds in controls, 0.390 seconds in patients, pre and 0.366 seconds post botulinum toxin. Our study with visual CPT reveals a difference in coherence between controls and patients in the following regions: fronto-frontal, fronto-parietal, fronto-striatal, fronto-occipital, parieto-parietal and temporo-parietal. Intrahemi-spheric and interhemispheric networks were affected. After 2 weeks of botulinum toxin injection, there was minimal change in coherence in frontal and temporal networks. Conclusion The overall difference in coherence in the frontal circuits between cases and controls during the visual CPT may reflect increased difficulty with task, which is suggested by clinical testing. Botulinum toxin is associated with minimal improvement with visual speed processing in CD patients

Education Research: Electronic patient portal enrollment and no-show rates within a neurology resident clinic

OBJECTIVE: To identify factors that affect appointment adherence and investigate the association of electronic patient portal (ePP) enrollment and patient adherence rates to appointments in the Neurology Resident Clinic (NRC). METHODS: Patients scheduled for an appointment during the months of October 2015, February 2016, and June 2016 in the NRC were included. ePP enrollment, date of clinic appointment, method of referral to the clinic, and key demographic criteria were collected. χ RESULTS: Patients with ePP enrollment had significantly lower rates of no-show (19% vs 27%) and higher rates of showed (59% vs 48%) compared to patients without ePP enrollment. Younger patients (18-49) had the highest rates of no-show (28%), while older patients (65+) had the lowest rates of no-show (17%). Caucasian patients had significantly lower rates of no-show compared to non-Caucasian patients (14% vs 24%). Non-English-speaking patients had high rates of no-show (34%). Patients with a physician referral had significantly lower rates of no-show (20% vs 28%) and higher rates of showed (61% vs 44%) compared to patients with a self-referral. CONCLUSIONS: Our study indicates that ePP enrollment, age, race, and physician referral might be associated with reduced no-show rates in the NRC

Quality improvement: improving primary care follow-up for stroke/TIA patients

Objective: Our goal was to increase compliance of post stroke/TIA patients to have a 50% show rate to PCP clinic within a 5-week period. Background: Primary care physician (PCP) visits are essential for monitoring stroke risk factors such as diabetes, hypertension. These risk factors are shown to be poorly controlled in patients who miss clinic visits, which results in worse outcomes. A patient\u27s poor understanding of outpatient scheduling following inpatient discharge is a factor which hinders compliance with follow up visits. Earlier outpatient follow-up and improved education has been shown to prevent readmissions among patients with stroke. Design/Methods: Inclusion criteria were patients with diagnosis of stroke or transient ischemic attack (TIA) with a PCP within the Henry Ford Health System. Patients were discharged from the stroke unit to their home or inpatient rehab. In a pre-intervention group, we assessed compliance of patients following up with their PCP within 5 weeks following discharge. Our hypothesis suggests that arranging for follow up appointments with the patient\u27s PCP/Neurologist prior discharge will improve follow up within 5 weeks of discharge. The importance of close follow up after Stroke or TIA was also discussed with patients prior to discharge. Results: During one month of preintervention data collection, 49 patient charts were reviewed. Only 13 (26.53%) of those patients were noted to have followed up with their PCP within 5 weeks. Following our intervention, patients\u27 follow up with their PCP increased to an average of 51% compliance. Data was tracked over an 11 month period. Conclusions: Pre-arranging follow up for stroke patients with their PCPs is an effective intervention to improve compliance in stroke patients. A subset of patients with logistical difficulty in keeping appointments was identified: Patients undergoing sub-acute rehab were less likely to follow up. Further research should focus on addressing factors impeding outpatient follow up

Cervical Dystonia and Executive Function: A Pilot Magnetoencephalography Study

Background: Cervical dystonia (CD) patients have impaired working memory, processing speed and visual-motor integration ability. We used magnetoencephalography (MEG) to investigate changes in cerebral oscillations in CD patients during an executive function test, before and after administration of botulinum toxin. Methods: MEG data were collected from five CD patients while they performed a visual continuous performance task (CPT), before and after they received a botulinum toxin injection. MEG data was also collected on five controls matched for age and gender. Coherence source imaging was performed to quantify network connectivity of subjects. Results: Controls demonstrated two errors with visual CPT; CD patients demonstrated six and three errors pre- and post-botulinum toxin respectively. After botulinum toxin, mean time from cue to correct response was 0.337 s in controls, 0.390 s in patients before botulinum toxin injection, and 0.366 s after the injection. Differences in coherence between controls and patients were found in the following brain regions: Fronto-frontal, fronto-parietal, fronto-striatal, fronto-occipital, parieto-parietal and temporo-parietal. Intrahemispheric and interhemispheric networks were affected. Post injection, there was minimal change in coherence in the above-mentioned networks. Discussion: Neuropsychological testing suggests difference in coherence in frontal circuits between CD cases and controls during the visual CPT, which may reflect subjects’ increased difficulty with the task. Botulinum toxin is associated with minimal improvement with executive function in CD

Cervical Dystonia and Executive Function: A Pilot Magnetoencephalography Study

BACKGROUND: Cervical dystonia (CD) patients have impaired working memory, processing speed and visual-motor integration ability. We used magnetoencephalography (MEG) to investigate changes in cerebral oscillations in CD patients during an executive function test, before and after administration of botulinum toxin. METHODS: MEG data were collected from five CD patients while they performed a visual continuous performance task (CPT), before and after they received a botulinum toxin injection. MEG data was also collected on five controls matched for age and gender. Coherence source imaging was performed to quantify network connectivity of subjects. RESULTS: Controls demonstrated two errors with visual CPT; CD patients demonstrated six and three errors pre- and post-botulinum toxin respectively. After botulinum toxin, mean time from cue to correct response was 0.337 s in controls, 0.390 s in patients before botulinum toxin injection, and 0.366 s after the injection. Differences in coherence between controls and patients were found in the following brain regions: Fronto-frontal, fronto-parietal, fronto-striatal, fronto-occipital, parieto-parietal and temporo-parietal. Intrahemispheric and interhemispheric networks were affected. Post injection, there was minimal change in coherence in the above-mentioned networks. DISCUSSION: Neuropsychological testing suggests difference in coherence in frontal circuits between CD cases and controls during the visual CPT, which may reflect subjects\u27 increased difficulty with the task. Botulinum toxin is associated with minimal improvement with executive function in CD