Neurology Commons^™

Migraine And Fasting, Lubna Ashraf Jafri, Mohammad Wasay

Pakistan Journal of Neurological Sciences (PJNS)

Migraine is considered as the second leading cause of disability worldwide, most commonly seen in young women. Skipping meals, dehydration and fasting are among many triggering factors which have been described in literature as a cause of increased frequency and severity of migraine attacks. The underlying pathophysiology, prevention and management of fasting induced migraine has been documented, however, there is a lack of randomized controlled trials for the same. This review article discusses these important aspects in the light of published literature and gives directions on future areas of research.

Evaluation Of Diazepam Nasal Spray In Patients With Epilepsy Concomitantly Using Maintenance Benzodiazepines: An Interim Subgroup Analysis From A Phase 3, Long-Term, Open-Label Safety Study., Eric B Segal, Daniel Tarquinio, Ian Miller, James W Wheless, Dennis Dlugos, Victor Biton, Gregory D Cascino, Jay Desai, R Edward Hogan, Kore Liow, Michael R Sperling, Blanca Vazquez, David F Cook, Adrian L Rabinowicz, Enrique Carrazana

Department of Neurology Faculty Papers

OBJECTIVE: Diazepam nasal spray (Valtoco), indicated for acute treatment of frequent seizure activity (seizure clusters) in patients with epilepsy ≥6 years of age, is designed to be a rapid, noninvasive, socially acceptable route of administration. This interim analysis evaluated the safety profile of diazepam nasal spray in patients with and without concomitant use of benzodiazepines, with use of a second dose for a seizure cluster as a proxy for effectiveness.

METHODS: A long-term, phase 3, open-label safety study enrolled patients with epilepsy who had seizures despite a stable antiseizure medication regimen.

RESULTS: Among 175 patients enrolled by October 31, 2019, …

Are Lumbar Fusion Guidelines Followed? A Survey Of North American Spine Surgeons, Thiago Montenegro, Christopher Elia, Kevin Hines, Zorica Buser, Jefferson Wilson, Zoher Ghogawala, Shekar N Kurpad, Daniel M Sciubba, James Harrop

Department of Neurosurgery Faculty Papers

OBJECTIVE: To evaluate the use of guidelines for lumbar spine fusions among spine surgeons in North America.

METHODS: An anonymous survey was electronically sent to all AO Spine North America members. Survey respondents were asked to indicate their opinion surrounding the suitability of instrumented fusion in a variety of clinical scenarios. Fusion indications in accordance with North America Spine Society (NASS) guidelines for lumbar fusion were considered NASS-concordant answers. Respondents were considered to have a NASS-concordant approach if ≥ 70% (13 of 18) of their answers were NASS-concordant answers. Comparisons were performed using bivariable statistics.

RESULTS: A total of 105 …

The Contribution Of Dysphagia To Acute Stroke Morbidity And Mortality In Nigeria: A Prospective Study, O O. Olajide, Philip Adebayo, F T. Taiwo, M O. Owolabi, A Ogunniyi

Internal Medicine, East Africa

Background: The assessment of time-trend morbidity and mortality in acute stroke is critical to clinical policy decisions and resource allocation.

Objectives: To determine the prevalence of dysphagia in acute stroke and the impact of dysphagia on short term stroke outcome (30 days post-stroke).

Methods: This was a prospective longitudinal study. Bedside screening for dysphagia modified Rankin score (MRS) and Barthel Index (BI) were performed on acute stroke patients on day 1, day 7, day 14 and day 30 after stroke to determine the frequency of dysphagia. Patients with dysphagia were then compared with age- and gender-matched controls (stroke patients without …

Anti-Nmda Receptor Encephalitis, Zaid Waqar, Haris Majid Rajput, Muhammad Hassan, Iqra Athar, Neelma Naz Khattak, Mazhar Badshah

Pakistan Journal of Neurological Sciences (PJNS)

Anti N-methyl-D-aspartate receptor (NMDA)receptor encephalitis is one of the most common type of auto immune encephalitis. Its diagnosis is often delayed due to initial clinical presentation with psychiatric clinical features. Initial clinical features resemble those of acute psychosis or depression which later evolve into frank neurological dysfunction. This was first described in association with ovarian teratoma, but it was later also found to exist without neoplastic association and in men as well. It occurs more frequently in younger age group, mostly below 50 years of age. Diagnosis is established with the help of cerebrospinal fluid (CSF) analysis for oligo clonal …

Gaba-B Encephalitis In Pakistan: A Rare But Treatable Entity, Asfandyar Khan Niazi, Shafain Shaikh, Arsalan Ahmad, Ayesha Zafar, Tahir Aziz Ahmed

Pakistan Journal of Neurological Sciences (PJNS)

Autoimmune and paraneoplastic encephalitides are a group of neurologic disorders that present with cognitive decline, neuropsychiatric symptoms, movement disorders, or seizures. These diseases can present before, with, or after the diagnosis of malignancy. We report two cases of GABA-B encephalitis from Pakistan. The first patient was a 67-year-old gentleman presented with cognitive decline and neuropsychiatric symptoms. His CSF analysis showed increased protein levels and GABA-B receptor antibodies. He was treated with pulse steroids, which improved his symptoms. The second patient was a 34-year-old lady with cognitive decline and psychomotor symptoms. Her serum autoimmune antibody panel showed antibodies against GABA-B receptors. …

Association Of Hypomagnesaemia & Hypocalcemia With Intracerebral Hemorrhage And Outcome, Muhammad Hassan, Naveed Ullah Khan, Mansoor Iqbal, Haris Majid Rajput, Ehsan-Ur- Rehman, Waleed Shahzad, Mazhar Badshah

Pakistan Journal of Neurological Sciences (PJNS)

Determine if hypomagnesemia & hypocalcemia on admission was associated with ICH and outcome.

Magnesium is a vascular smooth muscle relaxant and appears to provide protection against cellular injury in experimental stroke models. The implication of low serum magnesium in primary ICH is not well defined.

All patients with a primary ICH presented to PIMS, Islamabad prospectively analyzed in a pilot study. Demographics, initial lab values, ICH location, Mg+2 level, NIHSS & MRS at presentation were recorded. All patients with INR <= 1.5 were included in this study. We took normal serum magnesium in our study was 1.8 - 2.5 mEq/dL. Statistical significance was determined using linear regression adjusting for admission systolic blood pressure (SBP).

We identified 66 patients who met the inclusion criteria. The mean age was 52.76 years with minimum and maximum age …

Machine Learning Classification Of Traumatic Brain Injury Patients Versus Healthy Controls Using Arterial Spin Labeled Perfusion Mri, Vanessa I. Grass

Dissertations, Theses, and Capstone Projects

Traumatic brain injury (TBI) is one of the most common causes of death and disability worldwide, yet accurate in vivo detection of TBI neuropathology remains challenging due to complexities in the structural and functional changes observed post-injury as well as limitations in conventional neuroimaging modalities. Although advanced neuroimaging techniques such as arterial spin labeling (ASL) can noninvasively assess cerebral blood flow (CBF) changes observed post-injury, this technique is underutilized in TBI research partly due to the low signal-to-noise-ratio (SNR) inherent in ASL imaging. The aim of the current study is to examine the use of machine learning, specifically a Support …

Postdischarge 24/7 Hotline Service For Neurology And Neurosurgery Patients And 1-Year Impact On Readmission Rates, Unplanned Emergency Department Visits, And Patient Satisfaction, Shafqat Bibi, Rida Mitha, Kiran Bano, Farida Datoo, Nadia Karim, Muhammad Shahzad Shamim

School of Nursing & Midwifery

Objective: Telephone triage is a system in which trained nurses use standardized protocols to evaluate symptoms over the phone and determine the appropriate course of action.
Materials and methods: We implemented a protocol for systematic follow up phone calls and telephonic triage to families of neurology and neurosurgery patients after discharge, primarily to improve care transition and to assess its impact on the ratio of visits in the emergency department, readmissions, and overall satisfaction of patients and families. The intervention comprised the implementation of nurse led telephone triage and postdischarge follow up phone calls. After implementing hotline services in mind …

Aggressive Herpes Zoster In Young Patients With Multiple Sclerosis Under Dimethyl Fumarate: Significance Of Cd8, Maria Anagnostouli, Georgios Velonakis, Marinos Dalakas

Department of Neurology Faculty Papers

Dimethyl fumarate (DMF), approved for relapsing-remitting multiple sclerosis (RRMS), exerts immune-mediated mechanisms crucial for T-cell survival and migration, preferentially reducing CD8+ T cells.1 Although baseline absolute lymphocyte count (ALC) is considered the most critical predictor of developing lymphopenia,2 it was recently concluded that lymphocyte subset monitoring is not required for safety vigilance because T-cell subset reduction does not increase risks for serious infections.3 We present 2 young patients with RRMS, under DMF treatment, negative for HIV and SARSCoV-2 (by RT-PCR in nasal swab) and with normal follow-up white blood cell (WBC)/ALC counts, who developed severe herpes zoster (HZ) infection with …

Tolerability Of Switching Cholinesterase Inhibitors To Memantine Monotherapy Versus Adding Memantine As Combination Therapy For All-Cause Neurodegenerative Disorders, Estevana Isaac, Md, Mijail Serruya, Md, Phd, Keith Scott, Phd, Michael R. Sperling, Md, Carol Lippa, Md

Health Equity and Quality Improvement (HEQI) Summit

Background: Prior studies have focused on the clinical efficacy of combination therapy, Donepezil and Memantine, for patient’s diagnosed with Alzheimer’s disease. However, the potential adverse drug reactions while described as mild can have serious sequelae in older adults who are already managing the side effects of polypharmacy.

Objective: This study looks to explore the tolerability of switching cholinesterase inhibitors to memantine monotherapy versus adding memantine as combination therapy for all-cause neurodegenerative disorders.

Methods: The study is a retrospective chart review that includes 175 patients aged 50 and older diagnosed with neurocognitive disorders (ICD 10 F00-F03.91 and ICD10 G30-G31.84) managed on …

Addressing Health Disparities And Access In The Department Of Neurology Outpatient Setting In The Era Of The Covid-19 Pandemic: A Quality Improvement Initiative, V. Wang, M. Rehman, K. Burda, L. Liao, M. Braslavsky, T. Chuang, J. Diep, Md, E. Isaac, E. Wong

Health Equity and Quality Improvement (HEQI) Summit

Neurology, a largely outpatient specialty, has joined many other fields in the endeavor of incorporating telemedicine.^4,6,7 We present the results of analysis of the Epic Electronic Medical Record (EMR) of all outpatient visits from the Thomas Jefferson University Hospital Department of Neurology from 2019 to 2020 in order to identify areas of ethnic minority and geographic disparities with regards to usage of telemedicine. For our analyses, we have included Neurology patients across the General Neurology (JUP Neurology 909 Walnut NEU), Headache Center (HA), and Multiple Sclerosis Center (MS). Additionally, based on patient surveys from a subset of our outpatient …

Evaluating Advance Care Planning In Patients With Amyotrophic Lateral Sclerosis: A Retrospective Chart Review, Zachary Klock, Md, Stephanie Dobak, Rd, Gail Houseman, Rn, Margaret Kreher, Md, Facp

Health Equity and Quality Improvement (HEQI) Summit

• ALS is a progressive, degenerative neurologic disorder with inevitable decline in function and ultimately death.
• Most patients and families will be faced with decisions regarding mechanical ventilation and artificial nutrition.
• Prior studies have showed low rates of ACP completion in this population (<50%) and high rates of opt out in programs to aid ACP (nearly 40%).
• By reviewing charts of patients with ALS, we can analyze the impact of ACP on care utilization including artificial nutrition, mechanical ventilation and hospice utilization to help to guide efforts regarding ACP in the outpatient setting.

Alteplase Administration For Acute Ischemic Stroke (Ais) In Er - A 5-Year Review, Ali A. Saherwala, Md, Diana Tzeng, Md, Robin Dharia, Md

Health Equity and Quality Improvement (HEQI) Summit

• ER visits for AIS grown in last 10 years by 25%
• Ongoing effort by AHA/ASA to improve access to care with early stroke recognition and awareness
• Time is brain; rate of thrombolysis with alteplase (ALT) should increase with better EMS systems, awareness, and education

Improving Understanding Of And Compliance With Anti-Shivering Protocols During Therapeutic Hypothermia With Just-In-Time Training, Brittany Heckel, Md, Eunice Lee, Md, Courtney Curran, Md, Kasun Navarathna, Md, Henry Lee, Md, Lucy Maguire, Md, Phd, Malissa Pynes, Md, Shyam Majmundar, Md, Alexander Buslov, Md, Syed Shah, Md, Mba, Matthew Vibbert, Md

Health Equity and Quality Improvement (HEQI) Summit

• Therapeutic hypothermia after cardiac arrest has been demonstrated to improve neurologic outcomes and survival rates following cardiac arrest.
• Shivering during hypothermia increases metabolic demand, increases oxygen consumption and increases difficulty maintaining desired temperatures.
• Gaps in knowledge can lead to inadequate management of shivering, leading

Aims for Improvement

To improve understanding of and compliance with anti-shivering protocols during therapeutic hypothermia post-cardiac arrest.

Inflammatory Regulation Of Cns Barriers After Traumatic Brain Injury: A Tale Directed By Interleukin-1, Colleen N. Bodnar, James B. Watson, Emma K. Higgins, Ning Quan, Adam D. Bachstetter

Neuroscience Faculty Publications

Several barriers separate the central nervous system (CNS) from the rest of the body. These barriers are essential for regulating the movement of fluid, ions, molecules, and immune cells into and out of the brain parenchyma. Each CNS barrier is unique and highly dynamic. Endothelial cells, epithelial cells, pericytes, astrocytes, and other cellular constituents each have intricate functions that are essential to sustain the brain’s health. Along with damaging neurons, a traumatic brain injury (TBI) also directly insults the CNS barrier-forming cells. Disruption to the barriers first occurs by physical damage to the cells, called the primary injury. Subsequently, during …

Explicit Training To Improve Affective Prosody Recognition In Adults With Acute Right Hemisphere Stroke, Alexandra Zezinka Durfee, Shannon M. Sheppard, Erin L. Meier, Lisa Bunker, Erjia Cui, Ciprian Crainiceanu, Argye E. Hillis

Communication Sciences and Disorders Faculty Articles and Research

Difficulty recognizing affective prosody (receptive aprosodia) can occur following right hemisphere damage (RHD). Not all individuals spontaneously recover their ability to recognize affective prosody, warranting behavioral intervention. However, there is a dearth of evidence-based receptive aprosodia treatment research in this clinical population. The purpose of the current study was to investigate an explicit training protocol targeting affective prosody recognition in adults with RHD and receptive aprosodia. Eighteen adults with receptive aprosodia due to acute RHD completed affective prosody recognition before and after a short training session that targeted proposed underlying perceptual and conceptual processes. Behavioral impairment and lesion characteristics were …

Long Term Safety, Tolerability, And Efficacy Of Intracutaneous Zolmitriptan (M207) In The Acute Treatment Of Migraine., Stephanie J. Nahas, Nada Hindiyeh, Deborah I. Friedman, Nada Elbuluk, Donald J. Kellerman, Pamela K. Foreman, Peter Schmidt

Department of Neurology Faculty Papers

OBJECTIVE: To determine the long-term safety and tolerability profile of M207 in the acute treatment of migraine.

BACKGROUND: M207 is an investigational microneedle-based system for intracutaneous delivery of zolmitriptan for the treatment of migraine attacks. Following on the positive results of a Phase 2/3 placebo-controlled efficacy study (ZOTRIP), this study was designed to evaluate the safety of this novel product during repeated use for the treatment of migraine attacks.

METHODS: In this 6-12 month open-label, multicenter observational study, participants used an eDiary to record headache symptoms and adverse events at specified intervals up to 48 h following treatment of a …

Use Of Artificial Intelligence To Identify Predictors Of Functional Outcomes In Patients With Facioscapulohumeral Muscular Dystrophy, Natalie K. Katz

Research Days

Background: Facioscapulohumeral muscular dystrophy (FSHD) is one of the most common forms of muscular dystrophy characterized by slowly progressive muscle weakness. Symptoms initially involve the facial and shoulder girdle muscles, with later involvement of the distal lower extremities, pelvic girdle and proximal lower extremities. FSHD type 1 (FHSD1) is the most common form (~95% of individuals) and is caused by deletion of microsatellite repeats in the D4Z4 region on chromosome 4 (4q35). Normal individuals have >10 repeats whereas individuals with FSHD1 have 1-10 repeats. There is significant variability in regards to disease severity, rates of progression and functional outcomes, but …

Lessons Learned After 760 Neurointerventions Via The Upper Extremity Vasculature: Pearls And Pitfalls., Ahmad Sweid, Joshua H. Weinberg, Omaditya Khanna, Somnath Das, Julie Kim, Darcy Curtis, Batoul Hammoud, Kareem El Naamani, Rawad Abbas, Shyam Majmundar, Kalyan C. Sajja, Nohra Chalouhi, Fadi Al Saiegh, Nikolaos Mouchtouris, Elias Atallah, M. Reid Gooch, Nabeel A. Herial, Stavropoula Tjoumakaris, Victor Romo, Robert H. Rosenwasswer, Pascal Jabbour

Department of Neurosurgery Faculty Papers

BACKGROUND: The radial approach has been gaining more widespread use by neurointerventionalists fueled by data from the cardiology literature showing better safety and overall reduced morbidity.

OBJECTIVE: To present our institution's experience with the radial approach for neuroendovascular interventions in 614 consecutive patients who underwent a cumulative of 760 procedures.

METHODS: A retrospective analysis was performed and identified neuroendovascular procedures performed via the upper extremity vasculature access site.

RESULTS: Amongst 760 procedures, 34.2% (260) were therapeutic, and 65.7% (500) were nontherapeutic angiograms. Access sites were 71.5% (544) via a conventional radial artery, 27.8% (211) via a distal radial artery, 0.5% …