Cardioneuroablation in a Woman with Ictal-Induced Cardiac Asystole

Background: Ictal-induced cardiac bradyarrhythmia and asystole is a rare phenomenon. The exact mechanism of ictal-induced cardiac bradyarrhythmia and asystole remains unclear. It was postulated that stimulation of central autonomic network during ictal episode may trigger an abrupt burst of hypervagotonia. Prolonged episode of cardiac bradyarrhythmia and asystole may result in syncope or death due to impairment of cerebral perfusion. The role of cardioneuroablation (CNA) in this condition has not been well-described in the literature. Objective(s): To describe a case of successful CNA in a patient with ictal-induced bradyarrhythmia and asystole. Method(s): n/a Results: A 47-year-old female has a 1.5-year history of intractable focal epilepsy and COVID-19 infection. She started having multiple episodes of seizures following a mild COVID-19 infection. Electroencephalogram (EEG) and brain MRI revealed right temporal onset seizures without structural lesions. Due to ongoing uncontrolled seizures with multiple semiologies despite multiple anti-epileptic drugs, she was admitted to Epilepsy Monitoring Unit for seizure classification. Her ictal EEGs (Figure 1) showed onset of ictal rhythm in the right temporal region with episodes of severe sinus bradycardia (15-30 bpm) and sinus pauses (15-16 seconds). Telemetry tracings demonstrated PP interval slowing with PR interval prolongation prior to the pauses consistent with a vagally-mediated mechanism. Cardiac electrophysiology team recommended CNA for treating the episodes of ictal-induced bradyarrhythmia and asystole. 3D anatomic maps of the right atrium (RA) and left atrium (LA) were created using CARTO system (Biosense Webster). Right superior ganglionated plexus (RSGP) was localized with fractionation mapping and intracardiac echocardiography guidance. RSGP was targeted from the RA using an irrigated radiofrequency catheter with power limit of 25 W. Post-ablations of RSGP, her heart rate increased from 60 - 99 bpm. Additional lesions were delivered from the LA site but no additional heart rate increase was not seen. An implantable loop recorder was implanted post-ablation procedure. During follow-up of 8 months, she had recurrent focal epilepsy, but no bradyarrhythmias or asystole was noted on her loop recorder. Resting heart rates at long-term follow up were between 70 - 100 bpm. Conclusion(s): This case highlights the utility of CNA in patient with ictal-induced cardiac bradyarrhythmia and asystole. CNA may be an approach to avoid permanent pacemakers in this population. [Formula presented]Copyright © 2023

Infant with syndrome of inappropriate antidiuretic hormone secretion (SIADH) secondary to infant botulism

Objectives To become familiar with the appearance of SIADH in infant botulism Methods A-43 day old male with no significant history presented to the ED with difficulty latching and decreased activity for 2 days. At the ED, he was afebrile, hypoxic to 82% with moderate respiratory distress. Non-invasive positive pressure ventilation was started and he was placed on systemic antibiotics due to concern for sepsis. Initial labs showed positive rhinovirus/enterovirus, but otherwise normal CMP (Na 140 mmol/l), CBC, CRP, VBG, UA, negative COVID-19 and blood culture after 48 hours. CXR showed right upper lobe consolidation. Patient received a bolus of NS and maintenance IVF afterwards for less than 24 hours. He was placed on continuous orogastric feeds during the second day of hospitalization with his usual home formula regimen while weaning IVF. Patient started showing periorbital edema and his neurologic status deteriorated with hypotonia, diminished reflexes and lethargy. During the 5th day of hospitalization, he had a focal seizure of the left lower extremity that lasted about 2 minutes that promptly resolved after lorazepam administration. Labs sent during that episode were significant with Na of 113 mmol/l, urine Na of 94 mmol/l, urine Osm of 383 mOs/kg, and serum Osm of 271 mOs/kg consistent with SIADH, however, he did not have increased urine output. Rest of labs and imaging of the head and spine were normal. Patient received 0.9% NS and 3% hypertonic solution and sodium started to normalize over the course of 24 hours and remained stable during the rest of the hospital course on IV fluids. Due to profound hypotonia and aforementioned progressive clinical course while ruling out other possible causes with different specialties, concern for infant botulism was discussed and infectious disease was consulted. Recommendations included sending stool sample for botulism, avoiding the use of any aminoglycoside, and starting botulism immune globulin (BabyBIG) Results Patient received BabyBIG 50mg/kg about 10 days after initial admission and started improving immediately the day after administration. Neurologic status and respiratory effort subsequently started improving significantly and patient was able to be extubated after a week. Infant was eventually confirmed for botulism toxin A via stool Conclusions SIADH is thought to be due to reduced atrial filling from venous pooling in paralysis and is known to be a common complication of infant botulism and should be considered when patient has hyponatremia.

A RARE CASE OF POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES)

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: We are presenting a rare case of Posterior Reversible Encephalopathy Syndrome (PRES) without traditional risk factors in a patient with Covid 19. CASE PRESENTATION: Patient is a 41 y/o F with a past medical history of obesity, seizure disorder, epilepsy, hyperlipidemia and asthma who was admitted for Covid 19 pneumonia. Patient was transferred to the ICU on day #5 and intubated on day #8. Patient was given remdesivir, dexamethasone and baricitinib. Patient required intermittent vasopressors as her blood pressure varied between hypotensive and normotensive. Rarely her blood pressure increased to a hypertensive range. Patient had a thrombotic event on day #19 in her right upper extremity secondary to continuous renal replacement to manage acute renal failure. On Day #24, patient became unresponsive without sedation with an EEG showing moderate to severe slowing. On day #26 patient had a decreased response to stimuli leading to an MRI to evaluate for Posterior Reversible Encephalopathy Syndrome (PRES). MRI highlighted abnormal signal in the brain parenchyma concentrated mainly in the posterior brain consistent with PRES. On day #31 patient exhibited seizure like diffuse tremor. Blood pressure ranged from 90/72 to 137/84 hospital days #20-31. Status epilepticus was evaluated by an long term monitoring EEG showed diffuse slowing and occasional sharp wave activity in the right posterior cerebellum and occipital region without active seizures. On day #39 patient was found to have an acute hemorrhagic stroke of the left temporal region which resolved on day #43. On day #47 patient was transferred to a tertiary care center for tracheostomy placement and discharged on day #55 to a LTACH for rehab. DISCUSSION: PRES is a rare but severe complication of Covid 19 infection. Previous cases showed variability in underlying causes. Our patient showed significant endothelial dysfunction leading to multiple thrombotic events[1]. While our patient had rare hypertensive episodes, they were not persistent nor severe, nor were they present at the time of her seizure activity[1][2]. In comparison to previous cases, our patient had overlapping risk factors such as renal failure, obesity and dyslipidemia[1]. Our patient showed common clinical manifestations of PRES such as seizures, focal neurological deficits, and altered mental status with previous cases[1]. Our patient was not given tocilizumab in contrast with previous cases, however was given corticosteroids[1][2]. CONCLUSIONS: The above is a rare case of PRES without traditional risk factors. Providers must keep a wide differential diagnosis in patients with Covid 19. Reference #1: Lallana, S., Siegler, J. E., Chen, A., Requena, M., Rubiera, M., & Sanchez, A. (2021). Response to correspondence concerning "posterior reversible encephalopathy syndrome (PRES) associated with covid-19.” Journal of Clinical Neuroscience, 92, 189–190. https://doi.org/10.1016/j.jocn.2021.08.006 Reference #2: Kishfy, L., Casasola, M., Banankhah, P., Parvez, A., Jan, Y. J., Shenoy, A. M., Thomson, C., & AbdelRazek, M. A. (2020). Posterior reversible encephalopathy syndrome (PRES) as a neurological association in severe covid-19. Journal of the Neurological Sciences, 414, 116943. https://doi.org/10.1016/j.jns.2020.116943 DISCLOSURES: No relevant relationships by Arka Bhattacharya No relevant relationships by Benjamin Silverman

Severe Multifocal Cortical Encephalopathy Following COVID-19 Vaccination: A Case Report

Objective: This clinical case history details a woman who received the COVID-19 vaccine BNT162b2 and developed an acute, severe encephalopathy associated with new onset seizures within days of her first vaccination. Background: BNT162b2, an mRNA-LNP-vaccine, has been strategically purified and modified to suppress immunogenicity. It still possesses powerful intrinsic immune-stimulatory features that induce type-I INF production, which has been associated with both inflammation and potentially autoimmunity in several mRNA-vaccine phase-I/II clinical trials (HIVNCT02413645, influenza-NCT03076385, rabies-NCT02241135 and Zika virus-NCT03014089). Design/Methods: A 69-year-old woman who received her first dose of BNT162b2 five days prior, was found unresponsive. Within twenty-four hours of arrival, she developed focal seizures with secondary generalized, and remained in non-convulsive status epilepticus on longterm EEG monitoring until day 5 of admission despite three anti-seizure medications and a propofol drip. Brain MRI on day 3 of admission showed gyriform-pattern diffusion restriction in the right hemisphere and left frontoparietal region without features suggestive of an acute vascular event. Vascular imaging was normal. Cerebrospinal fluid examination revealed an elevated protein level (135 mg/dl), with negative findings for infections from bacteria, fungi, mycobacteria, HIV, syphilis, and viruses, including COVID-19 PCR, as well as paraneoplastic and autoimmune encephalitis panels. Serum COVID-19 IgG antibody was negative on post-immunization day 8. Results: There was no significant improvement following empiric methylprednisolone and meningitis antibiotic/antiviral treatment. She was discharged in a deeply comatose status on day 30 of hospital admission. Repeat MRI brain on day 14 showed similar findings to her previous scan with the addition of Wallerian degeneration in the right cerebral peduncle. Conclusions: In a patient who develops an acute encephalopathy with new onset of seizure within days of BNT162b2 vaccine, do consider mRNA-vaccine related encephalopathy in the differential diagnosis.

Ensuring the Continuity of Data Collection in a Focal Epilepsy Clinical Trial During the COVID-19 Pandemic

Objective: To ensure continuity of quality data collection by implementation of novel data capture measures whilst conducting an epilepsy clinical trial in the COVID-19 pandemic. Background: The COVID-19 Pandemic introduced unprecedented complexities in conducting clinical trial assessments at required timepoints via traditional participant visits to clinical sites. Implementation of novel approaches mid-stream to maintain continuity of care for trial participants and satisfy the objectives of the protocol were required. In an ongoing Ph 2 trial in patients with focal epilepsy , mitigations to allow remote collection of data were implemented due to restrictions related to COVID-19. Design/Methods: Based on trial objectives and key data collection timepoints, a protocol assessment determined which visits could be performed remotely. Specific methodology was applied to determine which assessments could be captured remotely via traditional telemedicine. Vendors were evaluated to support remote capture of datapoints not captured via telemedicine, and modifications were subsequently made to the protocol, informed consent form, and trial database. Relevant materials were submitted for IRB, regulatory authority, and ethics committee approval. Results: After IRB, regulatory authority and ethics committee approvals were received, modifications to data collection due to interference related to the COVID-19 pandemic included the introduction of home health care providers to collect lab draws and vital signs at participants' homes, Direct to Patient shipment of study drug, remote ECG collection, and allowance for scales to be conducted via telemedicine. Trial participants are consented to the use of these forms of data collection at their screening visit, and mitigations were successfully implemented across trial sites. Conclusions: To ensure continuity of trial participant care, quality data collection, and the prevention of lost trial data due to COVID-19 complications, modifications to allow remote capture of data were successfully implemented in an ongoing Ph 2 trial in patients with focal epilepsy. 1.

Evaluation of Patients Presenting to the Pediatric Emergency Department with Seizures during the COVID-19 Pandemic

The coronavirus disease 2019 pandemic has led to significant changes in hospital visits worldwide. The admission rates have remarkably decreased. This study investigates the characteristics of 104 patients (54 girls, 50 boys) who presented to our pediatric emergency department (ED) with seizures during the pandemic between May 2020 and May 2021. Regarding seizure type, 84 generalized and 20 focal seizures had occurred. Tonic, tonic-clonic, clonic, and hypomotor seizures were seen in descending order. Thirty-seven patients were diagnosed with epilepsy, and 32 patients with first afebrile, 25 first febrile, and 10 recurrent febrile seizures. No patients had acute symptomatic seizures. In 85 patients, the seizures had stopped before the ED visit;only one lasted >60 minutes. Benzodiazepines were administered as a first-line drug. Demographical features, electroencephalogram (EEG), and cranial imaging findings, laboratory test results, and distribution by month and by the hour of ED visit were analyzed. Study data was in accordance with the literature by seizure types, seizure management, and cranial imaging rates but differed by distribution in terms of month and the hour of ED visit. The EEG abnormality rate was higher among the first afebrile seizure cases. The number of patients with seizures was 69, that is, 0.3% of emergency admissions, for the 4 months of 2019 before the pandemic, and 104, that is, 0.4% of emergency admissions for the whole initial year of the pandemic thereafter. So, the number of patients with seizures had decreased, but their rate had increased, which could be attributed to a decrease in the number of nonurgent presentations to the ED during the pandemic.

Altered mental status in a woman with CoViD-19: A case of SARS-CoV-2 related encephalitis

Background: CoViD-19 has been shown to impact a variety of organs, including the CNS. The definition of Neuro-CoViD encompasses different pathologic conditions on a clinical, pathophysiological and prognostic level, which need a timely and accurate diagnosis. Presentation of the case: A 69-year-old woman was admitted 6 days after a diagnosis of SARS-CoV-2 infection with fever, moderate hypoxemic respiratory failure, and altered mental status (disorientation, lethargy, aphasia). No focal neurologic signs or nuchal rigidity were present. Brain MRI was unremarkable. The patient underwent EEG (generalized slowing) and CSF sampling, which showed hyperproteinorrachia (70mg/dl) and pleocytosis (9 cells/μl), with negative Gram staining. A diagnosis of encephalitis was made, and empiric treatment with dexamethasone, remdesivir, acyclovir, ampicillin was started. Screening for HIV and syphilis were negative. The day after the patient presented partial seizure and levetiracetam was added. A negative result was obtained from CSF culture and molecular testing for herpesvirus, Toscana virus, and SARS-CoV-2. The patient experienced gradual improvement in 10 days, obtaining normalization of mental status (Rankin scale 0). Conclusions: The present case adds to several reports of CoViD- 19-related encephalitis. The disease course is variable, with different patterns in neuroimaging and clinical presentation. Testing for SARS-CoV-2 on CSF is often negative, and neuroinflammatory or autoimmune responses could play a major role in brain damage. However, a direct viral CNS invasion cannot be excluded.