Publications by authors named "Sara E Hocker"

35 Publications

Hyperammonemia in Patients With Status Epilepticus Treated With or Without Valproic Acid.

Neurologist 2021 May 5;26(3):80-82. Epub 2021 May 5.

Department of Neurology, Mayo Clinic, Rochester, MN.

Background: Hyperammonemia is a common side effect of valproic acid (VPA) and can occur after generalized seizures, but the clinical significance is unclear. The aim of this study was to better understand the clinical practice and utility of ammonia testing in status epilepticus (SE) treated with or without VPA.

Methods: Charts of adult patients with SE from St. Mary's Hospital Intensive Care Units (ICUs) (Mayo Clinic, Rochester, MN) from 2011 to 2016 were reviewed. Clinical factors were compared between patients who had ammonia checked versus those who did not, and those with normal ammonia versus hyperammonemia (>50 µg/dL). Charts were reviewed to determine if hyperammonemia changed clinical management and if it was felt to be symptomatic.

Results: There were 304 patients identified: 94 received VPA, 142 had ammonia checked and receiving VPA was associated with ammonia testing (P<0.001). Hyperammonemia was identified in 32 and associated with younger age, being in a non-neurological intensive care unit, and liver disease, but was not statistically associated with VPA. Only one patient had valproate-induced hyperammonemic encephalopathy; however, many patients received treatment for hyperammonemia such as lactulose, levocarnitine, or VPA dose reductions.

Conclusions: This study demonstrated variability in ammonia testing and management changes in SE but does not support the routine monitoring of ammonia levels and showed that hyperammonemic encephalopathy was rare in this clinical setting.
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http://dx.doi.org/10.1097/NRL.0000000000000335DOI Listing
May 2021

Thalamic venous infarction from trauma mimicking a glioma.

Clin Imaging 2021 May 3;73:23-25. Epub 2020 Dec 3.

Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN 55905, United States of America. Electronic address:

Traumatic brain injuries (TBI) are commonly associated with motor vehicle accidents. Neuroimaging plays a crucial role in the initial management of TBIs. We present a case of a TBI related to a motor vehicle accident in an 18-year-old woman. Initial brain imaging revealed significant traumatic injuries and an enhancing mass, without restricted diffusion, in the thalamus favored to be a thalamic glioma. Subsequent imaging revealed resolution of enhancement of the thalamic lesion and reduction in size. On review of the original imaging, it was determined that the thalamic lesion was related to a tear and partial thrombosis of a large thalamic vein resulting in infarction and hemorrhage.
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http://dx.doi.org/10.1016/j.clinimag.2020.11.045DOI Listing
May 2021

Communication Challenges: A Spotlight on New-Onset Refractory Status Epilepticus.

Mayo Clin Proc 2019 05 29;94(5):857-863. Epub 2019 Mar 29.

Division of Critical Care Neurology, Department of Neurology, Mayo Clinic, Rochester, MN.

New-onset refractory status epilepticus (NORSE) is a rare, potentially devastating condition that occurs abruptly in previously healthy patients of any age but most commonly in children and young adults. It has an unpredictable clinical course requiring immediate, often prolonged, critical care support with multiple specialists involved and frequently results in severe life-altering sequelae or death. Communication in NORSE is challenging because its etiology in a given patient is initially unknown (and often remains so), the clinical course and outcome are unpredictable, and many health care team members are involved in the care of a patient. We address the communication challenges seen in NORSE through proactive communication on 3 levels: (1) in the shared decision-making process with the family, (2) within an individual hospital, and (3) across institutions. Intentional organizational change and enhanced information dissemination may help break down barriers to effective communication. Key initiatives for enhancing information dissemination in NORSE are (1) the identification of a most responsible physician to integrate information from subspecialties, to communicate frequently and candidly with the family, and to provide continuity of care over a prolonged period of time and (2) the early involvement of palliative care services alongside ongoing therapies with curative intent to support families and the medical team in decision making and communication.
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http://dx.doi.org/10.1016/j.mayocp.2018.12.004DOI Listing
May 2019

New onset refractory status epilepticus research: What is on the horizon?

Neurology 2019 04 20;92(17):802-810. Epub 2019 Mar 20.

From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT.

New-onset refractory status epilepticus (NORSE) is a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurologic disorder, with new onset of refractory status epilepticus (RSE) that does not resolve after 2 or more rescue medications, without a clear acute or active structural, toxic, or metabolic cause. Febrile infection-related epilepsy syndrome is a subset of NORSE in which fever began at least 24 hours prior to the RSE. Both terms apply to all age groups. Until recently, NORSE was a poorly recognized entity without a consistent definition or approach to care. We review the current state of knowledge in NORSE and propose a roadmap for future collaborative research. Research investigating NORSE should prioritize the following 4 domains: (1) clinical features, etiology, and pathophysiology; (2) treatment; (3) adult and pediatric evaluation and management approaches; and (4) public advocacy, professional education, and family support. We consider international collaboration and multicenter research crucial in achieving these goals.
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http://dx.doi.org/10.1212/WNL.0000000000007322DOI Listing
April 2019

Autoimmune Encephalitis Secondary to Melanoma.

Ann Intern Med 2019 06 12;170(12):905-906. Epub 2019 Feb 12.

Mayo Clinic, Rochester, Minnesota (A.D., G.G., S.M., A.Z., E.F.W., S.E.H.).

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http://dx.doi.org/10.7326/L18-0593DOI Listing
June 2019

West Nile virus induces a post-infectious pro-inflammatory state that explains transformation of stable ocular myasthenia gravis to myasthenic crises.

J Neurol Sci 2018 12 13;395:1-3. Epub 2018 Sep 13.

Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, MS, USA. Electronic address:

West Nile virus (WNV) infection has been reported to promote myasthenia gravis (MG) and various other diseases that have a presumed autoimmune pathogenesis. Molecular mimicry between WNV proteins and host proteins has been postulated as the major mechanism for WNV-triggered breaking of immunological self-tolerance. We present a patient with stable ocular MG and positive anti-acetylcholine receptor antibodies who progressed to myasthenic crisis after WNV neuroinvasive disease. In this case of stable autoimmune disease with proven auto-antibodies, transformation to generalized disease cannot be attributed to molecular mimicry, which requires that an immune response first be generated against an infectious agent. Rather, the evidence supports the concept of a post-infectious pro-inflammatory state that may contribute to the amplification and promotion of autoimmune disease in some WNV survivors.
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http://dx.doi.org/10.1016/j.jns.2018.09.015DOI Listing
December 2018

Bilateral independent periodic discharges are associated with electrographic seizures and poor outcome: A case-control study.

Clin Neurophysiol 2018 11 29;129(11):2284-2289. Epub 2018 Aug 29.

Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Service de Neurologie et Centre de Référence pour le Traitement de l'Epilepsie Réfractaire, Université Libre de Bruxelles - Hôpital Erasme, Bruxelles, Belgium. Electronic address:

Objective: To determine the clinical correlates bilateral independent periodic discharges (BIPDs) and their association with electrographic seizures and outcome.

Methods: Retrospective case-control study of patients with BIPDs compared to patients without periodic discharges ("No PDs") and patients with lateralized periodic discharges ("LPDs"), matched for age, etiology and level of alertness.

Results: We included 85 cases and 85 controls in each group. The most frequent etiologies of BIPDs were stroke, CNS infections, and anoxic brain injury. Acute bilateral cerebral injury was more common in the BIPDs group than in the No PDs and LPDs groups (70% vs. 37% vs. 35%). Electrographic seizures were more common with BIPDs than in the absence of PDs (45% vs. 8%), but not than with LPDs (52%). Mortality was higher in the BIPDs group (36%) than in the No PDs group (18%), with fewer patients with BIPDs achieving good outcome (moderate disability or better; 18% vs. 36%), but not than in the LPDs group (24% mortality, 26% good outcome). In multivariate analyses, BIPDs remained associated with mortality (OR: 3.0 [1.4-6.4]) and poor outcome (OR: 2.9 [1.4-6.2]).

Conclusion: BIPDs are caused by bilateral acute brain injury and are associated with a high risk of electrographic seizures and of poor outcome.

Significance: BIPDs are uncommon but their identification in critically ill patients has potential important implications, both in terms of clinical management and prognostication.
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http://dx.doi.org/10.1016/j.clinph.2018.07.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785981PMC
November 2018

At the Intersection of Patient Experience Data, Outcomes Research, and Practice: Analysis of HCAHPS Scores in Neurology Patients.

Mayo Clin Proc Innov Qual Outcomes 2018 Jun 24;2(2):137-147. Epub 2018 May 24.

Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.

Objective: To assess variation in patient-reported experience in inpatient neurology patients.

Patients And Methods: We retrospectively identified 1045 patients 18 years and older admitted to a neurology service and discharged from January 1, 2013, through September 30, 2016, who completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Multivariable logistic regression evaluated the associations of patient factors with HCAHPS measures. Key driver analysis identified associations between HCAHPS measures and the Global score (combination of 0-10 hospital rating and likelihood to recommend). Multivariable logistic regression compared HCAHPS scores between neurology patients and those admitted to a neurosurgery (n=2190) or internal medicine (n=3401) service during the same period.

Results: Among patients admitted to a neurology service, overall (summary) scores did not vary significantly by diagnosis after adjustment for age, education, and overall health, but patients with neurologic diagnoses other than stroke, epilepsy, and neurodegenerative disease were more likely to report lower Pain Management scores compared with patients with cancer. Key driver analysis showed Care Transition scores as drivers of the Global score. After adjustment, general internal medicine service patients were more likely to report low Summary scores and neurosurgery service patients were significantly less likely to report low Summary scores compared with neurology service patients.

Conclusion: Efforts to improve how neurology patients experience their care should be aimed at targeting patients' perceptions of pain management, and improving care transitions is an important first-priority target for improvement. This analysis may help other institutions improve hospital rating, value-based payments, and patient-centered outcomes.
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http://dx.doi.org/10.1016/j.mayocpiqo.2018.03.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6124338PMC
June 2018

A Future for Simulation in Acute Neurology.

Semin Neurol 2018 08 20;38(4):465-470. Epub 2018 Aug 20.

Department of Neurology, Mayo Clinic, Rochester, Minnesota.

Acute neurologic (and potentially disability prone) conditions are rarely taught and, if so, at the bedside and usually after the fact. Simulation training offers a realistic environment to teach rapid-fire decision making, how to take charge, and how best to approach a deteriorating, acutely ill neurologic patient.Simulating acute neurology is a newly emerging educational program. Proven principles of simulation, which may include teaching technical skills, can be applied to acute neurology (and neurointensive care). Communication skills pertaining to catastrophic neurologic injury with all its ethical ramifications can be taught and practiced. There is a growing need for well-designed, tested teaching scenarios and a need to validate this approach. This review provides an overview of the potential opportunities available in medical institutions with a simulation center.
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http://dx.doi.org/10.1055/s-0038-1666986DOI Listing
August 2018

Comparison of Ocular Ultrasonography and Magnetic Resonance Imaging for Detection of Increased Intracranial Pressure.

Front Neurol 2018 24;9:278. Epub 2018 Apr 24.

Department of Ophthalmology, Mayo Clinic, Rochester, NY, United States.

Background/aims: To evaluate and compare the performance of ocular ultrasonography (US) and magnetic resonance imaging (MRI) for detecting increased intracranial pressure (ICP) in patients with idiopathic intracranial hypertension (IIH).

Methods: Twenty-two patients with papilledema from IIH and 22 with pseudopapilledema were prospectively recruited based on funduscopic and clinical findings. Measurements of optic nerve sheath diameters (ONSDs) 3 mm behind the inner sclera were performed on B-scan US and axial T2-weighted MRI examinations. Pituitary-to-sella height ratio (pit/sella) was also calculated from sagittal T1-weighted MRI images. Lumbar puncture was performed in all patients with IIH and in five patients with pseudopapilledema.

Results: Average US and MRI ONSD were 4.4 (SD ± 0.7) and 5.2 ± 1.4 mm for the pseudopapilledema group and 5.2 ± 0.6 and 7.2 ± 1.6 mm for the papilledema group ( < 0.001). Average MRI pit/sella ratio was 0.7 ± 0.3 for the pseudopapilledema group and 0.3 ± 0.2 for the papilledema group ( < 0.001). Based on receiver-operator curve analysis, the optimal thresholds for detecting papilledema are US ONSD > 4.8 mm, MRI ONSD > 6.0 mm, and MRI pit/sella < 0.5. Combining a dilated US ONSD or MRI ONSD with a below-threshold MRI pit/sella ratio yielded a sensitivity of 73% and specificity of 96% for detecting IIH. Adding the US ONSD to the MRI ONSD and pit/sella ratio only increased the sensitivity by 5% and did not change specificity.

Conclusion: US and MRI provide measurements of ONSD that are well-correlated and sensitive markers for increased ICP. The combination of the ONSD and the pit/sella ratio can increase specificity for the diagnosis of IIH.
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http://dx.doi.org/10.3389/fneur.2018.00278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5928295PMC
April 2018

Systemic Complications Following Status Epilepticus.

Curr Neurol Neurosci Rep 2018 02 7;18(2). Epub 2018 Feb 7.

Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.

Purpose Of Review: Status epilepticus (SE) is a multisystem disorder. Initially, complications of a massive catecholamine release followed by the side effects of medical therapies, impact patients' outcomes. The aim of this article is to provide an updated summary of the systemic complications following SE.

Recent Findings: In recent years, the importance of the multifaceted nature of SE and its relationship with clinical outcomes has been increasingly recognized. The cumulative systemic effects of prolonged seizures and their treatment contribute to morbidity and mortality in this condition. Most systemic complications after SE are predictable. Anticipating their occurrence and respecting a number of simple guidelines may improve the prognosis of these patients.
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http://dx.doi.org/10.1007/s11910-018-0815-9DOI Listing
February 2018

Patient Management Problem-Preferred Responses.

Authors:
Sara E Hocker

Continuum (Minneap Minn) 2017 06;23(3, Neurology of Systemic Disease):906-914

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http://dx.doi.org/10.1212/CON.0000000000000476DOI Listing
June 2017

Patient Management Problem.

Authors:
Sara E Hocker

Continuum (Minneap Minn) 2017 06;23(3, Neurology of Systemic Disease):901-905

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http://dx.doi.org/10.1212/CON.0000000000000475DOI Listing
June 2017

Renal Disease and Neurology.

Authors:
Sara E Hocker

Continuum (Minneap Minn) 2017 06;23(3, Neurology of Systemic Disease):722-743

Purpose Of Review: Neurologic dysfunction is prevalent in patients with acute and chronic renal disease and may affect the central nervous system, peripheral nervous system, or both. Neurologic manifestations may result directly from the uremic state or as a consequence of renal replacement therapy. Early recognition of neurologic dysfunction may provide opportunities for intervention and reduced morbidity.

Recent Findings: Advances in the understanding of neurologic complications of renal disease and its treatments have led to more widespread recognition and earlier identification of encephalopathy syndromes such as cefepime neurotoxicity and posterior reversible encephalopathy syndrome (PRES), dramatic reductions in the incidence of dialysis disequilibrium syndrome and dialysis dementia, and improved survival in disorders such as von Hippel-Lindau disease and thrombotic thrombocytopenic purpura.

Summary: This article summarizes the conditions that affect both the renal and the nervous systems, the effects of renal failure on the nervous system, and the neurologic complications of dialysis.
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http://dx.doi.org/10.1212/CON.0000000000000469DOI Listing
June 2017

Extensive Mobile Thrombus of the Internal Carotid Discovered After Intravenous Thrombolysis: What Do I Do Now?

Neurohospitalist 2017 Apr 20;7(2):96-99. Epub 2016 Aug 20.

Mayo Clinic, Rochester, MN, USA.

This case report describes a rare presentation of ischemic stroke secondary to an extensive internal carotid artery thrombus, subsequent therapeutic dilemma, and clinical management. A 58-year-old man was administered intravenous (IV) thrombolysis for right middle cerebral artery territory ischemic stroke symptoms. A computed tomography angiogram of the head and neck following thrombolysis showed a longitudinally extensive internal carotid artery thrombus originating at the region of high-grade calcific stenosis. Mechanical embolectomy was deferred because of risk of clot dislodgement and mild neurological symptoms. Recumbency and hemodynamic augmentation were used acutely to support cerebral perfusion. Anticoagulation was started 24 hours after thrombolysis. Carotid endarterectomy was completed successfully within 1 week of presentation. Clinical outcome was satisfactory with discharge modified Rankin Scale score 0. A longitudinally extensive carotid artery thrombus poses a risk of dislodgement and hemispheric stroke. Optimal management in these cases is not known with certainty. In our case, IV thrombolysis, hemodynamic augmentation, delayed anticoagulation, and carotid endarterectomy resulted in a favorable clinical outcome.
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http://dx.doi.org/10.1177/1941874416663280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5382649PMC
April 2017

IV fosphenytoin in obese patients: Dosing strategies, safety, and efficacy.

Neurol Clin Pract 2017 Feb;7(1):45-52

Mayo Clinic, Rochester, MN.

Background: Previous studies evaluated the disposition of IV phenytoin loading doses and found that obese patients had increased drug distribution into excess body weight, larger volumes of distribution, and longer half-lives when compared to their nonobese counterparts. We assess the safety and efficacy of fosphenytoin loading doses in patients with different body mass indices (BMIs).

Methods: A retrospective chart review was conducted in 410 patients who received fosphenytoin. Patients were divided into 2 groups: BMI <30 (nonobese) and BMI ≥30 (obese). Patient demographics, fosphenytoin dose administered in mg/kg body weight, renal and liver function tests, fosphenytoin drug levels, and pre- and post-fosphenytoin administration vital signs were collected to assess for adverse events. Necessity of additional antiepileptic loading doses was used as a surrogate for clinical efficacy.

Results: The median dose of fosphenytoin administered was 19 mg/kg (interquartile range 15-20). The most frequently encountered adverse event was hypotension, which occurred in 39% of the cohort. Using a Bonferroni adjustment for multiple comparisons, there were no differences in adverse events between the 2 groups. The need for additional antiepileptic loading doses was not different between the 2 groups ( = 0.07).

Conclusions: The incidence of adverse events and the need for repeat loading antiepileptic medications was similar between the 2 groups. From our findings, the patients in our study did not receive empiric loading dose adjustments and the current method of loading fosphenytoin achieves similar outcomes, regardless of the patient's BMI.
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http://dx.doi.org/10.1212/CPJ.0000000000000322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5964862PMC
February 2017

Neurologic Complications of Commonly Used Drugs in the Hospital Setting.

Curr Neurol Neurosci Rep 2016 Apr;16(4):35

Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

This chapter reviews the neurologic complications of medications administered in the hospital setting, by class, introducing both common and less common side effects. Detail is devoted to the interaction between pain, analgesia, sedation, and their residual consequences. Antimicrobials are given in nearly every hospital setting, and we review their capacity to produce neurologic sequelae with special devotion to cefepime and the antiviral treatment of human immunodeficiency virus. The management of hemorrhagic stroke has become more complex with the introduction of novel oral anticoagulants, and we provide an update on what is known about reversal of the new oral anticoagulants. Both central and peripheral nervous system complications of immunosuppressants and chemotherapies are reviewed. Because diagnosis is generally based on clinical acumen, alone, neurotoxic syndromes resulting from psychotropic medications may be easily overlooked until severe dysautonomia develops. We include a practical approach to the diagnosis of serotonin syndrome and neuroleptic malignant syndrome.
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http://dx.doi.org/10.1007/s11910-016-0636-7DOI Listing
April 2016

Prompt Recognition and Management of Postoperative Intracranial Hypotension-Associated Venous Congestion: A Case Report.

Neurocrit Care 2016 06;24(3):448-53

Department of Critical Care Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Background: Postoperative intracranial hypotension-associated venous congestion (PIHV) is an uncommon cause of clinical deterioration after a neurosurgical procedure that is often unrecognized until late in its course. Functional outcomes range from remarkable neurological recovery to death. Little is understood about the reason for deterioration in certain patients compared with improvement in others. A 68-year-old man with a progressive cervical myelopathy underwent an uncomplicated cervical decompression and alignment restoration at our hospital and suffered violent generalized tonic-clonic seizures intraoperatively and postoperatively. A postoperative head CT showed a right parietal hematoma, but no other cranial findings. A subsequent MRI demonstrated what we describe as early PIHV with symmetric T2 signal changes in the bilateral deep gray structures. No diffusion restriction corresponded to these areas. A CT myelogram revealed a considerable CSF collection within the operative bed. Upon returning to the operating room to localize the source of the leak, a large dural tear was identified off of midline with a bone chip alongside the defect. The defect was repaired, and the patient remained comatose for over a week postoperatively. He made a remarkable gradual recovery, and after a month in the hospital and rehabilitation, he returned home with relatively minimal neurological deficits.

Conclusions: We postulate that if caught early and treated aggressively, neurologic injury resulting from PIHV may be reversible despite initially ominous imaging. Neurosurgeons and neurointensivists should therefore be compelled to search for dural defects and return to the operating room for immediate repair.
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http://dx.doi.org/10.1007/s12028-015-0207-9DOI Listing
June 2016

Status Epilepticus.

Authors:
Sara E Hocker

Continuum (Minneap Minn) 2015 Oct;21(5 Neurocritical Care):1362-83

Purpose Of Review: Status epilepticus, which is simultaneously a neurologic and systemic emergency, often results in significant disability and may be fatal. This article presents a pragmatic approach to the evaluation and management of status epilepticus in adults for the practicing clinician.

Recent Findings: Rapid recognition, treatment respecting a written protocol, and careful attention to potential complications may limit sequelae. Studies aimed at earlier identification of etiologies in cryptogenic status epilepticus and improving the treatment of established status epilepticus are urgently needed to limit the development of refractoriness.

Summary: This article reviews the guidelines and up-to-date information on the use of both pharmacologic and nonpharmacologic therapies in status epilepticus and discusses the shifts in our understanding of the balance between the need for aggressive control of seizures and the risks of treatment. This article also presents a suggested approach to the evaluation and management of common types of status epilepticus and explores future directions.
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http://dx.doi.org/10.1212/CON.0000000000000225DOI Listing
October 2015

Autoimmune Encephalitis in the ICU: Analysis of Phenotypes, Serologic Findings, and Outcomes.

Neurocrit Care 2016 Apr;24(2):240-50

Department of Neurology, College of Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.

Background: To report the clinical and laboratory characteristics, clinical courses, and outcomes of Mayo Clinic, Rochester, MN, ICU-managed autoimmune encephalitis patients (January 1st 2003-December 31st 2012).

Methods: Based on medical record review, twenty-five patients were assigned to Group 1 (had ≥1 of classic autoimmune encephalitis-specific IgGs, n = 13) or Group 2 (had ≥3 other characteristics supporting autoimmunity, n = 12).

Results: Median admission age was 47 years (range 22-88); 17 were women. Initial symptoms included ≥1 of subacute confusion or cognitive decline, 13; seizures, 12; craniocervical pain, 5; and personality change, 4. Thirteen Group 1 patients were seropositive for ≥1 of VGKC-complex-IgG (6; including Lgi1-IgG in 2), NMDA-R-IgG (4), AMPA-R-IgG (1), ANNA-1 (1), Ma1/Ma2 antibody (1), and PCA-1 (1). Twelve Group 2 patients had ≥3 other findings supportive of an autoimmune diagnosis (median 4; range 3-5): ≥1 other antibody type detected, 9; an inflammatory CSF, 8; ≥1 coexisting autoimmune disease, 7; an immunotherapy response, 7; limbic encephalitic MRI changes, 5; a paraneoplastic cause, 4; and diagnostic neuropathological findings, 2. Among 11 patients ICU-managed for ≥4 days, neurological improvements were attributable to corticosteroids (5/7 treated), plasmapheresis (3/7), or rituximab (1/3). At last follow-up, 10 patients had died. Of the remaining 15 patients, 6 (24%) had mild or no disability, 3 (12%) had moderate cognitive problems, and 6 (24%) had dementia (1 was bed bound). Median modified Rankin score at last follow-up was 3 (range 0-6).

Conclusions: Good outcomes may occur in ICU-managed autoimmune encephalitis patients. Clinical and testing characteristics are diverse. Comprehensive diagnostics should be pursued to facilitate timely treatment.
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http://dx.doi.org/10.1007/s12028-015-0196-8DOI Listing
April 2016

Prognostic and Mechanistic Factors Characterizing Seizure-Associated Crossed Cerebellar Diaschisis.

Neurocrit Care 2016 Apr;24(2):258-63

Department of Neurology, Mayo Clinic, Rochester, MN, USA.

Background: Crossed cerebellar diaschisis is a rare finding of hemispheric cerebellar depression following contralateral cerebral injury, hypothesized to result from excessive neuronal excitatory synaptic activity along cortico-pontine-cerebellar pathways. The phenomenon is typically observed following ischemic stroke, but has also been characterized during seizure activity--in particular, status epilepticus (SE). Neurological outcome has varied widely in published reports, with some patients achieving full neurologic recovery, while others experience persistent disability.

Methods: Case report and literature review.

Results: We present a 54-year-old man found unresponsive with a right hemispheric syndrome several days after discharge following amygdalohippocampectomy for refractory right temporal lobe epilepsy. Prolonged electroencephalogram demonstrated one subclinical right frontal seizure, along with right frontal periodic lateralized epileptiform discharges, presumed to be associated with SE preceding his admission. Initial MRI demonstrated restricted diffusion on diffusion weighted imaging in the right cerebral hemisphere, ipsilateral thalamus, and contralateral cerebellum. A head CT one week later showed diffuse sulcal effacement with loss of gray-white differentiation in the right frontal and insular regions with low attenuation changes of right thalamus. An MRI showed worsened diffusion restriction, despite a corresponding increase in perfusion. The patient remained paretic at discharge and follow-up. Follow-up MRI at 2 months demonstrated pronounced right cerebral and left cerebellar atrophy, loss of gray matter in much of the right cerebrum, and scattered areas of T2 hyperintensity, consistent with permanent right fronto-temporal neuronal loss.

Conclusions: Collectively, these observations indicate that imaging findings of persistent cerebral restricted diffusion and cytotoxic edema in the subacute post-ictal period may predict irreversible neuronal injury and poor long-term outcome-even when accompanied by evidence of cortical hyperperfusion and recovery of second- and third-order neurons along the involved circuit.
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http://dx.doi.org/10.1007/s12028-015-0155-4DOI Listing
April 2016

Influence of antithrombotics on the etiology of intracerebral hemorrhage.

J Stroke Cerebrovasc Dis 2015 Mar 16;24(3):699-703. Epub 2015 Jan 16.

Department of Neurology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: To determine the influence of antithrombotic use on the etiology of primary intracerebral hemorrhage (ICH).

Methods: We conducted a retrospective review of consecutive patients admitted with primary ICH from 2009 to 2012. Data recorded included age, history of hypertension, and use of antithrombotic medications. Imaging was reviewed to determine hemorrhage location and the presence and the location of any microhemorrhages. Etiologies were classified using a predetermined algorithm, which was based on existing literature.

Results: In total, 292 patients were included. Median age was 74 years (range, 18-101), and 52% were male (n = 151). Hemorrhage etiology was hypertension in 50.6% (n = 148), indeterminate in 29.5% (n = 86), and cerebral amyloid angiopathy (CAA) in 19.9% (n = 58). Most patients were on antithrombotics (61.3%, n = 179). Nearly half of the patients (49%) were 75 years of age or older, and the most common etiology in this group was hypertension (n = 77, 53%). There was a nonsignificant trend toward older age and CAA-ICH (median age, 77 years; interquartile range [IQR], 70-82 years) compared with other causes (median age, 74 years; IQR, 61-82 years; P = .07). There was no difference between CAA-ICH and other-cause ICH with respect to proportion of patients on antithrombotics in general (67% versus 60%; P = .367) or anticoagulants in particular (24% versus 25%; P = 1.000).

Conclusions: The most common ICH etiology in this study was hypertension, regardless of age. Our findings do not suggest that the higher occurrence of ICH in older patients or in patients with CAA-associated ICH is because of a higher frequency of anticoagulant use.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.11.009DOI Listing
March 2015

Postencephalitic epilepsy: clinical characteristics and predictors.

Epilepsia 2015 Jan 19;56(1):133-8. Epub 2014 Dec 19.

Department of Neurology, Mayo Clinic, Rochester, Minnesota, U.S.A.

Objective: To describe the etiologies, clinical presentations, outcomes, and predictors of postencephalitic epilepsy (PE) in a large series of adult patients with acute encephalitis.

Methods: We conducted a retrospective review of patients diagnosed with acute encephalitis at Mayo Clinic, Rochester, between January 2000 and December 2012. The patients were categorized into two groups based on the presence or absence of PE at last follow-up. Multivariate logistic regression analysis was used to analyze factors associated with PE.

Results: We identified 198 consecutive patients (100 [50.5%] male and 98 [49.5%] female) with a median age of 58 years (range 41.8-69). Etiologies included viral infection (n=95, 48%), autoimmune (n=44, 22%), and unknown/others (n=59, 30%). During hospitalization, seizures were seen in patients with autoimmune encephalitis (n=24, 54.5%), unknown/others (n=20, 33.9%), and viral encephalitis (n=23, 24.2%). Interictal epileptiform discharges on electroencephalography (EEG) were present in 34 (54%), whereas periodic lateralized epileptiform discharges (PLEDs) and generalized periodic discharges (GPDs) were seen in 14 (41.2%) and 2 (5.9%) patients. Forty-six patients with seizures (70.8%) had fluid-attenuated inversion recovery (FLAIR)/T2 abnormalities, 20 (31.3%) diffusion abnormalities, and 43 (66.2%) cortical involvement. Good outcome at discharge among patients with seizures was seen in 8/23 patients with viral etiology (34.8%), 10/24 patients with autoimmune encephalitis (45.5%), and 12/20 patients with unknown cause (60%). PE was present in 43 patients (29.9%). On multivariate regression analysis, the factors associated with PE were generalized seizures during hospitalization (p=0.03), focal seizures (p≤0.001), and the presence of FLAIR/T2 abnormalities on brain magnetic resonance imaging (MRI) (p=0.003).

Significance: The presence of seizures during hospitalization and an abnormal brain MRI are the strongest predictors of the development of PE. The etiology of encephalitis, presence of focal neurologic deficits, and interictal EEG abnormalities did not influence the development of PE.
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http://dx.doi.org/10.1111/epi.12879DOI Listing
January 2015

Neurologic complications of sepsis.

Continuum (Minneap Minn) 2014 Jun;20(3 Neurology of Systemic Disease):598-613

Purpose Of Review: This article reviews the current understanding of sepsis, a critical and often fatal illness that results from infection and multiorgan failure and impacts the brain, peripheral nervous system, and muscle.

Recent Findings: Encephalopathy occurs early in association with sepsis, and its severity correlates with mortality. Neuroimaging in patients with CNS manifestations is typically normal. EEG is nonspecific. EMG is commonly diagnostic, showing a combination of nerve and muscle injury already early in the clinical course. Rapid recognition and correction of reversible causes of encephalopathy and avoidance of risk factors for intensive care unit-acquired weakness may limit sequelae. Major deficiencies in our understanding of the complications of sepsis remain. Studies to improve the recognition and rehabilitation of these patients are imperative in a clinical syndrome affecting countless patients each year.

Summary: The risk of later cognitive and physical disability may be increased after sepsis; therefore, attention to neurologic complications is urgent.
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http://dx.doi.org/10.1212/01.CON.0000450968.53581.ffDOI Listing
June 2014

Neurologist versus machine: is the pupillometer better than the naked eye in detecting pupillary reactivity.

Neurocrit Care 2014 Oct;21(2):309-11

Department of Neurology, Mayo Clinic, Mary Brigh 8-D, 200 First Street SW, Rochester, MN, 55905, USA,

Background: A 62-year-old man with severe traumatic brain injury developed postsurgical anisocoria in which there was a discrepancy between pupillometer and manual testing.

Methods: Case report.

Results: The patient's larger pupil was read as unreactive by the pupillometer but constricted 1 mm over 7-9 s of continuous light stimulation.

Conclusions: While pupillometry assessment is a valuable adjunct to the manual pupillary assessment, this case demonstrates that nonreactive pupils read on the pupillometer should be confirmed with the manual examination because it can miss very slowly reacting pupils.
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http://dx.doi.org/10.1007/s12028-014-9988-5DOI Listing
October 2014

Ketogenic diet for adults in super-refractory status epilepticus.

Neurology 2014 Feb 22;82(8):665-70. Epub 2014 Jan 22.

From the Departments of Neurology (K.T.T., J.C.P., E.H.K., R.G.G., A.L.H., A.V., M.C.C.) and Pediatrics (E.H.K., A.L.H.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Department of Food and Nutrition Services (K.R.), Rush University Medical Center, Chicago, IL; Institute for Clinical and Translational Research (B.H.), Johns Hopkins University, Baltimore; Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore; and Departments of Anesthesiology-Critical Care Medicine, Neurosurgery, and Medicine (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD.

Objective: To describe a case series of adult patients in the intensive care unit in super-refractory status epilepticus (SRSE; refractory status lasting 24 hours or more despite appropriate anesthetic treatment) who received treatment with the ketogenic diet (KD).

Methods: We performed a retrospective case review at 4 medical centers of adult patients with SRSE treated with the KD. Data collected included demographic features, clinical presentation, diagnosis, EEG data, anticonvulsant treatment, and timing and duration of the KD. Primary outcome measures were resolution of status epilepticus (SE) after initiation of KD and ability to wean from anesthetic agents.

Results: Ten adult patients at 4 medical centers were started on the KD for SRSE. The median age was 33 years (interquartile range [IQR] 21), 4 patients (40%) were male, and 7 (70%) had encephalitis. The median duration of SE before initiation of KD was 21.5 days (IQR 28) and the median number of antiepileptic medications used before initiation of KD was 7 (IQR 7). Ninety percent of patients achieved ketosis, and SE ceased in all patients achieving ketosis in a median of 3 days (IQR 8). Three patients had minor complications of the KD including transient acidosis and hypertriglyceridemia and 2 patients ultimately died of causes unrelated to the KD.

Conclusion: We describe treatment of critically ill adult patients with SRSE with the KD, with 90% of patients achieving resolution of SE. Prospective trials are warranted to examine the efficacy of the KD in adults with refractory SE.

Classification Of Evidence: This study provides Class IV evidence that for intensive care unit patients with refractory SE, a KD leads to resolution of the SE.
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http://dx.doi.org/10.1212/WNL.0000000000000151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945660PMC
February 2014

Efficacy of a reduced electroencephalography electrode array for detection of seizures.

Neurohospitalist 2014 Jan;4(1):6-8

Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA.

Background: The expertise required for proper electroencephalography (EEG) setup can make the 10-20 array unwieldy in the hospital setting. There may be a role for an EEG array with reduced leads to improve the efficiency of inpatient practice.

Methods: Clips from 100 EEG records, 50 ictal and 50 non-ictal, in adult inpatients from January 1, 2007, to January 1, 2012, were retrospectively reviewed and selected for digital lead reduction and blind review. Two epileptologists reviewed these tracings and documented the presence of seizures and severe disturbance of background. The reduced array included 7 leads spanning the scalp. Three different montages were available. Sensitivity and specificity of the reduced array were calculated using the formal EEG report as the comparison standard.

Results: For the detection of any seizure, the reduced array EEG had a sensitivity of 70% and specificity of 96%. Sensitivity for identifying encephalopathic patterns was 62% and specificity was 86%. Focal seizures were more readily identified by the reduced array (20 of 25) than were generalized ictal patterns (13 of 25).

Conclusion: The reduced electrode array was insufficiently sensitive to seizure detection. Reducing EEG leads might not be a preferred means of optimizing hospital EEG efficiency.
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http://dx.doi.org/10.1177/1941874413507930DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869310PMC
January 2014

Neurologic complications of liver transplantation.

Handb Clin Neurol 2014 ;121:1257-66

Division of Critical Care Neurology, College of Medicine, Mayo Clinic, Rochester, MN, USA.

A new spectrum of neurologic complications has appeared with treatment of the organ transplant recipient. There are specific problems in liver recipients. Most pertinent is the management of acute fulminant hepatic failure and emerging brain edema that can only be definitively treated with acute liver transplantation. In some patients neurologic complications appear as a result of immunosuppressive drugs or due to infectious complications in immunocompromised patients. Neurologists seeing patients in a transplant unit should be prepared to see confused or obtunded critically ill patients with multiple medical problems, procedures, and polypharmacy. This chapter discusses the challenges of the transplant team and the consulting neurologist.
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http://dx.doi.org/10.1016/B978-0-7020-4088-7.00085-7DOI Listing
April 2014

Cefepime neurotoxicity in the intensive care unit: a cause of severe, underappreciated encephalopathy.

Crit Care 2013 Nov 7;17(6):R264. Epub 2013 Nov 7.

Introduction: Cefepime, a broad spectrum antibiotic, is commonly prescribed in intensive care units (ICU) and may be an overlooked cause of neurologic symptoms such as encephalopathy, myoclonus, seizures, and coma. We aimed to characterize cefepime neurotoxicity in the ICU.

Methods: We performed a retrospective study of adult ICU patients treated with intravenous cefepime for at least 3 days between January 1, 2009 and December 31, 2011. The primary outcome was the development of cefepime neurotoxicity, with the likelihood of causality ascribed via a modified Delphi method.

Results: This study included 100 patients. The mean age was 65.8 years (± 12.7 years). The median daily average dose of cefepime was 2.5 (IQR 2.0 to 3.5) grams. The median treatment duration was 6 (IQR 4 to 10) days. Renal failure in any form was present in 84 patients. Chronic kidney disease affected 40 patients, and 77 had acute kidney injury. Cefepime neurotoxicity occurred in 15 patients. Of these, seven were considered definite cases, three probable, and five possible. Neurotoxic symptoms included impaired consciousness (n = 13), myoclonus (n = 11), disorientation (n = 6), and nonconvulsive status epilepticus (n = 1). The dose of cefepime was appropriately adjusted for renal clearance in 64 patients (75.3%) without cefepime neurotoxicity and four patients (28.6%) with neurotoxicity (P = 0.001). Chronic kidney disease was present in 30 patients (35.3%) without neurotoxicity and in 10 (66.7%) of those with neurotoxicity (P = 0.04).

Conclusions: Critically ill patients with chronic kidney disease are particularly susceptible to cefepime neurotoxicity. Myoclonus and impaired consciousness are the predominant clinical manifestations. Neurotoxic symptoms occur more often when the cefepime dose is not adjusted for renal function, but can still occur despite those modifications.
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http://dx.doi.org/10.1186/cc13094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4057506PMC
November 2013