Factors Associated With Postoperative Confusion and Prolonged Hospital Stay Following Deep Brain Stimulation Surgery for Parkinson Disease

BACKGROUND

Several patient and disease characteristics are thought to influence DBS outcomes; however, most previous studies have focused on long-term outcomes with only a few addressing immediate postoperative course.

OBJECTIVE

To evaluate predictors of immediate outcomes (postoperative confusion and length of postoperative hospitalization) following deep brain stimulation surgery (DBS) in Parkinson disease (PD) patients.

METHODS

We conducted a retrospective study of PD patients who underwent DBS at our institution from 2006 to 2011. We computed the proportion of patients with postoperative confusion and those with postoperative hospitalization longer than 2 d. To look for associations, Fisher's exact tests were used for categorical predictors and logistic regression for continuous predictors.

RESULTS

We identified 130 patients [71% male, mean age: 63 ± 9.1, mean PD duration: 10.7 ± 5.1]. There were 7 cases of postoperative confusion and 19 of prolonged postoperative hospitalization. Of the 48 patients with tremors, none had postoperative confusion, whereas 10.1% of patients without tremors had confusion (P = .0425). Also, 10.2% of patients with preoperative falls/balance-dysfunction had postoperative confusion, whereas only 1.6% of patients without falls/balance-dysfunction had postoperative confusion (P = .0575). For every one-unit increase in score on the preoperative on-UPDRS III/MDS-UPDRS III score, the odds of having postoperative confusion increased by 10% (P = .0420). The following factors were noninfluential: age, disease duration, dyskinesia, gait freezing, preoperative levodopa-equivalent dose, number of intraoperative microelectrode passes, and laterality/side of surgery.

CONCLUSION

Absence of tremors and higher preoperative UPDRS III predicted postoperative confusion after DBS in PD patients. Clinicians' awareness of these predictors can guide their decision making regarding patient selection and surgical planning.

Current and emerging therapeutics for neuromyelitis optica spectrum disorder: Relevance to the COVID-19 pandemic

Neuromyelitis optica spectrum disorder (NMOSD) can lead to immobility and bulbar weakness. This, in addition to the older age of onset and the higher rate of hospitalization compared to multiple sclerosis, makes this patient group a potential target for complicated COVID-19 infection. Moreover, many of the commonly used preventive therapies for NMOSD are cell-depleting immunouppsressants with increased risk of viral and bacterial infections. The emergence of several new NMOSD therapeutics, including immune-modulating agents, concurrently with the worldwide spread of the COVID-19 global pandemic call for careful therapeutic planning and add to the complexity of NMOSD management. Altering the common therapeutic approach to NMOSD during the pandemic may be necessary to balance both efficacy and safety of treatment. Selection of preventive therapy should take in consideration the viral exposure risk related to the route and frequency of administration and, most importantly, the immunological properties of each therapeutic agent and its potential impact on the risk of SARS-CoV-2 susceptibility and severity of infection. The impact of the therapeutic agent on the immune response against the future SARS-CoV-2 vaccine should also be considered in the clinical decision-making. In this review, we will discuss the immune response against SARS-CoV-2 and evaluate the potential impact of the current and emerging NMOSD therapeutics on infection risk, infection severity, and future SARS-CoV-2 vaccination. We propose a therapeutic approach to NMOSD during the COVID-19 pandemic based on analysis of the mechanism of action, route of administration, and side effect profile of each therapeutic agent.

The pressing questions in multiple sclerosis Care in the era of COVID-19

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MS patients should continue their disease modifying therapy during the pandemic.

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Newly diagnosed patients should start disease modifying therapy without delay.

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The effect on COVID-19 infection and future vaccination should be considered.

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Agents that cause prolonged non-selective lymphopenia are not preferred.

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Only severe relapses should be treated preferably with oral steroids at home.

Case Report: Postvaccination Anti-Myelin Oligodendrocyte Glycoprotein Neuromyelitis Optica Spectrum Disorder: A Case Report and Literature Review of Postvaccination Demyelination

Stimulation of the immune response after vaccination can occasionally result in adverse effects, including demyelination of the central nervous system. The most common presentation of postvaccination demyelination is acute disseminated encephalomyelitis, but cases of optic neuritis, transverse myelitis, and multiple sclerosis relapses have been reported. More recently, an increasing number of postvaccination neuromyelitis optica spectrum disorder (NMOSD) cases have surfaced in the literature, especially in patients with aquaporin-4 antibodies. In this article, we report an unusual case of myelin oligodendrocyte glycoprotein antibody-related NMOSD after the receipt of multiple vaccines in a first-trimester pregnant woman from Africa. We review the reported cases of postvaccination demyelination in the past decade, with a focus on the relationship between NMOSD and vaccination in patients with aquaporin-4 or myelin oligodendrocyte glycoprotein antibodies. Finally, we discuss the clinical relevance of the present case and similar reported cases as it relates to patient care in the neuroimmunology clinic and identify potential areas for future research.

Multiple Sclerosis Disease-Modifying Therapy and the COVID-19 Pandemic: Implications on the Risk of Infection and Future Vaccination

The coronavirus 2019 (COVID-19) pandemic is expected to linger. Decisions regarding initiation or continuation of disease-modifying therapy for multiple sclerosis have to consider the potential relevance to the pandemic. Understanding the mechanism of action and the possible idiosyncratic effects of each therapeutic agent on the immune system is imperative during this special time. The infectious side-effect profile as well as the route and frequency of administration of each therapeutic agent should be carefully considered when selecting a new treatment or deciding on risk mitigation strategies for existing therapy. More importantly, the impact of each agent on the future severe acute respiratory syndrome coronavirus type-2 (SARS-CoV-2) vaccine should be carefully considered in treatment decisions. Moreover, some multiple sclerosis therapies may have beneficial antiviral effects against SARS-CoV-2 while others may have beneficial immune-modulating effects against the cytokine storm and hyperinflammatory phase of the disease. Conventional injectables have a favorable immune profile without an increased exposure risk and therefore may be suitable for mild multiple sclerosis during the pandemic. However, moderate and highly active multiple sclerosis will continue to require treatment with oral or intravenous high-potency agents but a number of risk mitigation strategies may have to be implemented. Immune-modulating therapies such as the fumerates, sphinogosine-1P modulators, and natalizumab may be anecdotally preferred over cell-depleting immunosuppressants during the pandemic from the immune profile standpoint. Within the cell-depleting agents, selective (ocrelizumab) or preferential (cladribine) depletion of B cells may be relatively safer than non-selective depletion of lymphocytes and innate immune cells (alemtuzumab). Patients who develop severe iatrogenic or idiosyncratic lymphopenia should be advised to maintain social distancing even in areas where lockdown has been removed or ameliorated. Patients with iatrogenic hypogammaglobulinemia may require prophylactic intravenous immunoglobulin therapy in certain situations. When the future SARS-CoV-2 vaccine becomes available, patients with multiple sclerosis should be advised that certain therapies may interfere with mounting a protective immune response to the vaccine and that serological confirmation of a response may be required after vaccination. They should also be aware that most multiple sclerosis therapies are incompatible with live vaccines if a live SARS-CoV-2 vaccine is developed. In this article, we review and compare disease-modifying therapies in terms of their effect on the immune system, published infection rates, potential impact on SARS-CoV-2 susceptibility, and vaccine-related implications. We propose risk mitigation strategies and practical approaches to disease-modifying therapy during the COVID-19 pandemic.

Height and weight changes after deep brain stimulation in patients with Parkinson disease: role of clinical subtypes

Increased body mass index (BMI) after deep brain stimulation (DBS) in Parkinson's disease (PD) has been repeatedly reported in literature. However, little is known about the effect of PD clinical subtypes on weight and height changes after DBS. We aimed to study the differential effect of tremor-predominant versus hypokinetic-rigid disease on weight and height changes after DBS.

METHODOLOGY

we chart-reviewed PD patients who underwent DBS at our center from 2006 to 2011. Weight and height data were obtained at the pre-surgical period, at 1-year post-surgery, and at the latest available follow-up (LAF).

RESULTS

There were 130 patients in the dataset (70% male, mean age 63+/-9.1). Eighty-eight patients had available data at 1-year post-DBS or longer. Mean LAF was 4.36+/-1.64 years. A BMI increment by 1 Kg/m2 or more was noticed in 35% after 1-year. Increased height (1cm-or-more) was seen in 24% of patients at 1-year. At 1-year post-DBS, 41.8% of patients with hypokinetic-rigid subtype increased in height compared to only 14.2% in the tremor-predominant group (OR 4.3, 95 % CI 1.3167-14.1246, P=0.015). There was no correlation between PD subtype and weight change after DBS.

CONCLUSION

This study confirms BMI increase after DBS in PD patients and reports a novel finding of increased height after DBS in patients with hypokinetic-rigid PD. This might be secondary to improved axial rigidity following DBS. Resolution of tremor is probably unrelated to the increase in body weight after surgery since weight gain did not differ between patients with tremor-predominant and those with hypokinetic-rigid subtype.

Electroencephalography and Epilepsy Course at UH Cleveland Medical Center, Cleveland, Ohio, United States

Prof. Hans Lüders organized the first International Electroencephalography (EEG)/Epilepsy course in Cleveland (Ohio, United States) in 1979. His vision was to impart a framework of basic knowledge in EEG and epilepsy. The course participants are assumed to have no prior knowledge of EEG or epilepsy. As such, the course is structured and paced to meet the expectations set forth by the organizing committee at the completion of the course. The curriculum has evolved over the years to reflect advancement of the field. There is an added emphasis on semiology (seizure semiology) and epileptic disorders. Also, the course content has expanded to include broader topics such as the intersection between epilepsy and sleep medicine for both adults and children. The course lasts 8 weeks and is offered twice a year, free of charge, in winter and summer at the University Hospital in Cleveland, Ohio, United States. The average class size ranges from 25 to 30, composed of individuals from around the world. The class hours are generally from 8 a.m. to 3:30 p.m. Daily attendance is expected as new concepts quickly build on previous ones. Midterm and final examinations are used for evaluations. Both written and verbal feedbacks on homework assignments are given daily. At the end of the course, a certificate of completion is awarded. The purpose of this article is to discuss the structural details of this intensive educational course that has been offered for 40 years.

Iatrogenic CNS demyelination in the era of modern biologics

The number of reported cases of iatrogenic demyelination of the central nervous system (CNS) is on the rise. This is, in part, related to the recent expansion in the use of biologics. Review of literature from the past decade suggests that in addition to vaccines, tumor necrosis factor (TNF)-alpha inhibitors and checkpoint inhibitors are the most frequently cited inducers of central inflammation. About one-third of demyelinating cases in the setting of TNF-alpha inhibitors evolve into full-blown multiple sclerosis. In addition to demyelination, checkpoint inhibitors may also cause accelerated paraneoplastic encephalitis and other antibody-mediated conditions. Luckily, the overall prognosis of iatrogenic central inflammation is favorable, with most cases having partial or complete response to steroids and discontinuation of the offending agent. Long-term monitoring and initiation of maintenance immune-modulating therapy may be necessary in some patients. In this article, we provide an updated review of biologic-induced inflammation of the CNS.

Movement disorders in early MS and related diseases: A prospective observational study

BACKGROUND

Little is known about the true prevalence and clinical characteristics of movement disorders in early multiple sclerosis (MS) and related demyelinating diseases. We conducted a prospective study to fill this knowledge gap.

METHODS

A consecutive patient sample was recruited from the MS clinic within a 1-year-period. Patients diagnosed over 5 years before the study start date were excluded. Each eligible patient was interviewed by a movement disorder neurologist who conducted a standardized movement disorder survey and a focused examination. Each patient was followed prospectively for 1-4 follow-up visits. Movement disorders identified on examination were video-recorded and videos were independently rated by a separate blinded movement expert.

RESULTS

Sixty patients were included (56.6% female, mean age 38.3 ± 12.7 years). Eighty percent reported one or more movement disorders on the survey and 38.3% had positive findings on examination. After excluding incidental movement disorders (e.g., essential tremor), 58.3% were thought to have demyelination-related movement disorders. The most common movement disorders in a descending order were restless legs syndrome, tremor, tonic spasms, myoclonus, focal dystonia, spontaneous clonus, fasciculations, pseudoathetosis, hyperekplexia, and hemifacial spasm. The movement disorder started 5 months following a relapse on average but in 8 patients it was the presenting symptom of a new relapse or the disease itself. The majority of movement disorders occurred secondary to spinal (85.7%) or cerebellar/brainstem lesions (34.2%). Spinal cord demyelination was the only statistically significant predictor of demyelination-related movement disorders.

CONCLUSION

Movement disorders are more common than previously thought even in early MS. They typically begin a few months after spinal or brainstem/cerebellar relapses but may occasionally be the presenting symptom of a relapse.

Acute ischemic stroke management in Lebanon: obstacles and solutions

Management of acute stroke varies greatly within and between different countries. This study assesses the current practices of physicians in Lebanon routinely involved in ischemic stroke (IS) management. We conducted a prospective observational study of patients hospitalized at 8 different Lebanese hospitals in the period August 1, 2015 to July 31, 2016, with a diagnosis of acute stroke. Baseline characteristics and data on diagnostic studies, as well as treatments received during hospitalization and at discharge, were collected and analyzed. Two hundred and three strokes/transient ischemic attacks (TIAs) were recorded but only 173 patients (85%) with ischemic events were included in the study. The patients' mean age was 69.8±12.7 years. All underwent brain imaging (CT scan and/or MRI) on admission. All ISs were managed by a neurologist, and patient management included consultation of a cardiologist. Hypertension was the most prevalent risk factor (78.6%), followed by a current cigarette smoking habit (50.3%), diabetes mellitus (42.8%), hypercholesterolemia (39.9%), previous stroke or TIA (17.3%), and atrial fibrillation (14.7%). Only four patients (accounting for 2.5% of the ISs) received thrombolytic therapy. More than 89% of the patients were discharged on at least one anti-hypertensive drug, 89.2% on statins and 37.6% on antidiabetic medications. More than 55% of patients were dependent at discharge, as shown by a modified Rankin Scale (mRS) score of 0-2, whereas 33% were independent (mRS score of 3-5). There are many challenges facing stroke care in Lebanon, and there is potential for improvement in this setting. Reperfusion therapy is still largely underused and remains a major challenge in achieving guideline-based reperfusion goals.

Prevalence of asthma in multiple sclerosis: A United States population-based study

BACKGROUND

Multiple sclerosis (MS) and asthma are complex multifactorial diseases which adversely impact daily functioning. However, the prevalence of asthma in those with MS is not clear. The objective of this study is to characterize the prevalence of asthma in those with MS, with considerations for age, gender, and race.

METHODS

We conducted a U.S. population-based, cross-sectional study of electronic health record information for 56.6 million Americans available in the IBM® Explorys EPM: Explore database. We evaluated the prevalence of asthma in MS (N = 141,880) and non-MS (N = 56,416,790) cohorts, stratifying by age, gender, and race (All, White Americans, and African Americans).

RESULTS

The prevalence of asthma was significantly greater among those with MS than the general population across age, gender, and racial subpopulations. Adjusting for age and gender, asthma was three times more common in MS. In the MS cohort, the prevalence of asthma had a U-shaped distribution with respect to age, with the greatest asthma prevalence among the young and the elderly (> 20% prevalence among those <30 or ≥80 years; prevalence range: 15 to 30%); this significantly differed from the fairly uniform distribution observed in the non-MS cohort (prevalence range: 4 to 9%). These patterns were relatively consistent when stratifying by gender and race.

CONCLUSION

Asthma is significantly more common in those with MS than in the general population - particularly in the young and elderly - irrespective of gender and race. The results add to the growing MS comorbidity literature, and emphasizes the need for comorbidity management as a part of comprehensive MS patient care.

Neuromodulation in multiple sclerosis

Neuromodulation, or the utilization of advanced technology for targeted electrical or chemical neuronal stimulation or inhibition, has been expanding in several neurological subspecialties. In the past decades, immune-modulating therapy has been the main focus of multiple sclerosis (MS) research with little attention to neuromodulation. However, with the recent advances in disease-modifying therapies, it is time to shift the focus of MS research to neuromodulation and restoration of function as with other neurological subspecialties. Preliminary research supports the value of intrathecal baclofen pump and functional electrical stimulation in improving spasticity and motor function in MS patients. Deep brain stimulation can improve MS-related tremor and trigeminal neuralgia. Spinal cord stimulation has been shown to be effective against MS-related pain and bladder dysfunction. Bladder overactivity also responds to sacral neuromodulation and posterior tibial nerve stimulation. Despite limited data in MS, transcranial magnetic stimulation and brain-computer interface are promising neuromodulatory techniques for symptom mitigation and neurorehabilitation of MS patients. In this review, we provide an overview of the available neuromodulatory techniques and the evidence for their use in MS.

Triaging Patients with Multiple Sclerosis in the Emergency Department: Room for Improvement

Background

Patients with multiple sclerosis (MS) present to the emergency department (ED) for various reasons. Although true relapse is rarely the underlying culprit, ED visits commonly result in new magnetic resonance imaging (MRI) and neurology admissions. We studied ED visits in patients with MS and evaluated decision making regarding diagnostic/therapeutic interventions and visit outcomes. We identified potential areas for improvement and used the data to propose a triaging algorithm for patients with MS in the ED.

Methods

We reviewed the medical records from 176 ED visits for patients with MS in 2014.

Results

Ninety-seven visits in 75 patients were MS related (66.6% female; mean ± SD age, 52.6 ± 13.8 years; mean ± SD disease duration, 18.5 ± 10.5 years). Thirty-three visits were for new neurologic symptoms (category 1), 29 for worsening preexisting symptoms (category 2), and 35 for MS-related complications (category 3). Eighty-nine visits (91.8%) resulted in hospital admission (42.7% to neurology). Only 39% of ordered MRIs showed radiographic activity. New relapses were determined in 27.8% of the visits and were more prevalent in category 1 compared with category 2 (P = .003); however, the two categories had similar rates of ordered MRIs and neurology admissions.

Conclusions

New relapse is a rare cause of ED visits in MS. Unnecessary MRIs and neurology admissions can be avoided by developing a triaging system for patients with MS based on symptom stratification.

Spinal Movement Disorders in Neuromyelitis Optica: An Under-recognized Phenomenon

Background

Spinal cord demyelination can cause several movement disorders. Although these abnormal movements could be the presenting symptom of the disease and, at times, the major source of disability, they are often overlooked, mislabeled, or undertreated. The aims of this study were to clearly define and establish common terminology for spinal movement disorders (SMDs) and characterize their full spectrum in patients with neuromyelitis optica (NMO).

Methods

We chart reviewed 37 patients with NMO or NMO spectrum disorder. We classified spinal movement disorders under five categories: tonic spasms; focal dystonia; spinal myoclonus; spontaneous clonus; and tremors of spinal origin. We examined clinical, MRI, and medication data of symptomatic patients.

Results

Of the 37 patients (86.4% female; mean age: 51 ± 17 years; mean disease duration: 9.4 ± 5.3 years), 16 (43.2%) had one or more form of SMDs. Compared to those without SMDs, patients with SMDs were generally older at presentation and were less likely to be African Americans. An abnormal movement was the main complaint in at least one posthospitalization visit in all symptomatic patients. Thirteen (35.1%) patients had paroxysmal tonic spasms, 2 (5.4%) had focal dystonia, 3 (8%) had postural/action tremors, and no patient had spinal myoclonus or spontaneous clonus. In 9 patients, spasms were painful. There was no signal abnormality in the basal ganglia or the brainstem/cerebellum in any of the symptomatic patients.

Conclusions

SMDs are common in NMO and are often a major source of disability. Using clear, unified terminology to describe SMDs is crucial for both clinical and research purposes.

Swollen eyelid reveals multiple intracranial hydatid cysts associated with a palpebral cyst

We report a case of a hydatid cyst of the eyelid in a 12-year-old boy associated with cerebral involvement. The patient was initially treated by neurosurgeons for brain cysts. The course after an interval of two months was marked by regression of the palpebral cyst on albendazole.

Treatment of acute relapses in neuromyelitis optica: Steroids alone versus steroids plus plasma exchange

BACKGROUND

Although adding plasma exchange (PLEX) to steroids in severe neuromyelitis optica (NMO) attacks is common practice in steroid-resistant cases, the benefit of this strategy has not been previously quantified.

OBJECTIVE

The objective of this paper is to compare the efficacy of high-dose intravenous methylprednisolone (IVMP) versus IVMP+PLEX in treatment of acute NMO relapses.

METHODS

We conducted a retrospective review of the last 83 NMO admissions to the Johns Hopkins Hospital treated with IVMP alone versus IVMP+PLEX (for steroid-resistant cases). Extended Disability Status Scale (EDSS) score was calculated at baseline, at presentation, at discharge, and on follow-up.

RESULTS

Eighteen NMO relapses (16 patients, 87% female, mean age at relapse: 33.9±23.8, median baseline EDSS 2.5) were treated with IVMP alone and 65 relapses (43 patients, 95% female, mean age at relapse: 43.8±15.7, median baseline EDSS 5.75) were treated with IVMP + PLEX. Sixty-five percent of IVMP + PLEX patients achieved an EDSS equal or below their baseline at follow-up while only 35% of the IVMP-only patients achieved their baseline EDSS on follow-up (odds ratio=3.36, 95% CI 1.0657 to 10.6004, p = 0.0386). PLEX was more effective in improving EDSS in patients on preventive immunosuppressive medications at time of relapse.

CONCLUSIONS

PLEX+IVMP are more likely to improve EDSS after NMO relapses compared to IVMP alone, especially in patients taking preventive medications.

Comprehensive, Multidisciplinary Deep Brain Stimulation Screening for Parkinson Patients: No Room for "Short Cuts"

Careful, often cumbersome, screening is a fundamental part of DBS evaluation in Parkinson's disease (PD). It often involves a brain MRI, neuropsychological testing, neurological, surgical, and psychiatric evaluation, and "ON/OFF" motor testing. Given that DBS has now been a standard treatment for advanced PD, with clinicians' improved comfort and confidence in screening and referring patients for DBS, we wondered whether we can now streamline our lengthy evaluation process. We reviewed all PD patients evaluated for DBS at our center between 2006 and 2011 and analyzed the reasons for exclusion and for dropping out despite passing the screening process. A total of 223 PD patients who underwent DBS evaluation had complete charting. Only 131 (58.7%) patients were successfully implanted. Sixty-one (27.3%) patients were excluded after screening because of significant cognitive decline (32.7%), early disease with room for medication adjustment (29.5%), behavioral dysfunction (21.3%), suspected secondary parkinsonism or atypical parkinsonism syndrome (13.1%), PD, but with poor levodopa response (11.4%), unrealistic goals (9.8%), PD with predominant axial symptoms (6.5%), significant comorbidities (6.5%), or abnormal brain imaging (3.2%). In addition, 31 (13.9%) patients were cleared for surgery, but either chose not have it (18 patients), were lost to follow-up (12 patients), or were denied by medical insurance (1 patient). Through careful screening, a significant percentage of surgical candidates continue to be identified as less suitable because of a variety of reasons. This underscores the continued need for a comprehensive, multidisciplinary screening process.