Acute epileptiform abnormalities are the primary predictors of post-stroke epilepsy: a matched, case-control study.

Stroke patients who underwent continuous EEG (cEEG) monitoring within 7 days of presentation and developed post-stroke epilepsy (PSE; cases, n = 36) were matched (1:2 ratio) by age and follow-up duration with ones who did not (controls, n = 72). Variables significant on univariable analysis [hypertension, smoking, hemorrhagic conversion, pre-cEEG convulsive seizures, and epileptiform abnormalities (EAs)] were included in the multivariable logistic model and only the presence of EAs on EEG remained significant PSE predictor [OR = 11.9 (1.75-491.6)]. With acute EAs independently predicting PSE development, accounting for their presence may help to tailor post-acute symptomatic seizure management and aid anti-epileptogenesis therapy trials.

Seizure Risk in Patients Undergoing 30-Day Readmission After Continuous EEG Monitoring.

PURPOSE: The use of continuous electroencephalographic (cEEG) monitoring has improved the understanding of the seizure risk during acute hospitalization. However, the immediate posthospitalization seizure risk in these patients remains unknown. Patients undergoing 30-day readmission after initial cEEG monitoring were analyzed to fill this knowledge gap. METHODS: A prospectively maintained cEEG database (January 1, 2015-December 31, 2015) was used to identify adults who underwent a repeat cEEG during their 30-day readmission after cEEG during their index hospitalization (index cEEG). Various demographical, clinical, and cEEG variables were extracted including indication for cEEG: altered mental status and clinical seizure-like events. RESULTS: A total of 57 of the 2,485 (2.3%) adults undergoing index cEEG during the study period had concerns for seizures and underwent repeat cEEG during a 30-day readmission. These patients were almost three times more likely to have suffered electrographic seizure on the index admission (odds ratio, 2.82; 95% confidence interval, 1.54-5.15; P < 0.001) compared with non-readmitted patients. Seizure-like events led to the readmission of 40.4% patients. Close to one in five (19.3%) readmitted patients were found to have an electrographic seizure. Only variable predictive of seizure on readmission was seizure-like events (odds ratio, 6.4; 95% confidence interval, 1.2-33.0; P = 0.02). CONCLUSIONS: A small percentage of patients have clinical presentation concerning for seizures with in 30 days after index cEEG. The risk of electrographic seizures in this patient population is higher than patients who have cEEG monitoring but do not undergo a 30-day readmission requiring repeat cEEG. Future research on early identification of patients at risk of 30-day readmission because of concerns for seizure is needed.

Paradoxical and Retrograde Air Embolism from Pressurized Peripheral Bolus.

INTRODUCTION: Cerebral air embolism is a rare, yet serious neurological occurrence with unclear incidence and prevalence. Here, we present a case of fatal cerebral arterial and venous cerebral gas embolism in a patient with infective endocarditis and known large right-to-left shunt and severe tricuspid regurgitation following pressurized fluid bolus administration. Case Presentation. A 32-year-old female was admitted to the medical intensive care unit from a long-term acute care facility with acute on chronic respiratory failure. Her medical history was significant for intravenous heroin and cocaine abuse, methicillin-sensitive Staphylococcus aureus tricuspid valve infective endocarditis on vancomycin, patent foramen ovale, septic pulmonary embolism with cavitation, tracheostomy with chronic ventilator dependence, multifocal cerebral infarction, hepatitis C, nephrolithiasis, anxiety, and depression. After intravenous fluid administration, she became unresponsive with roving gaze, sluggish pupils, and hypotensive requiring vasopressors. CT of the brain showed diffuse arterial and venous cerebral air embolism secondary to accidental air administration from fluid bolus. Magnetic resonance imaging of the brain showed diffuse global anoxic injury and flattening of the globe at the optic nerve insertion. Given poor prognosis, her family chose comfort measures and she died. CONCLUSIONS: Fatal cerebral air embolism can occur through peripheral intravenous routes when the lines are inadequately primed and fluids administered with pressure. Caution must be exercised in patients with right-to-left shunting as air may gain access to systemic circulation.

COVID-19 Disease and Hypercoagulability Leading to Acute Ischemic Stroke.

INTRODUCTION: SARS-Coronavirus-2 infection leading to COVID-19 disease presents most often with respiratory failure. The systemic inflammatory response of SARS-CoV-2 along with the hypercoagulable state that the infection elicits can lead to acute thrombotic complications including ischemic stroke. We present 3 cases of patients with COVID-19 disease who presented with varying degrees of vascular thrombosis. CASES: Cases 1 and 2 presented as cerebral ischemic strokes without respiratory failure. Given their exposure risks, they were both tested for COVID-19 disease. Case 2 ultimately developed respiratory failure and pulmonary embolism. Cases 2 and 3 were found to have simultaneous arterial and venous thromboembolism (ischemic stroke and pulmonary embolism) as well as positive antiphospholipid antibodies. CONCLUSION: Our case series highlight the presence of hypercoagulability as an important mechanism in patients with COVID-19 disease with and without respiratory failure. Despite arterial and venous thromboembolic events, antiphospholipid and hypercoagulable panels in the acute phase can be difficult to interpret in the context of acute phase response and utilization of thrombolytics. SARS-CoV-2 testing in patients presenting with stroke symptoms may be useful in communities with a high case burden or patients with a history of exposure.

Electroencephalographic Abnormalities are Common in COVID-19 and are Associated with Outcomes.

OBJECTIVE: The aim was to determine the prevalence and risk factors for electrographic seizures and other electroencephalographic (EEG) patterns in patients with Coronavirus disease 2019 (COVID-19) undergoing clinically indicated continuous electroencephalogram (cEEG) monitoring and to assess whether EEG findings are associated with outcomes. METHODS: We identified 197 patients with COVID-19 referred for cEEG at 9 participating centers. Medical records and EEG reports were reviewed retrospectively to determine the incidence of and clinical risk factors for seizures and other epileptiform patterns. Multivariate Cox proportional hazards analysis assessed the relationship between EEG patterns and clinical outcomes. RESULTS: Electrographic seizures were detected in 19 (9.6%) patients, including nonconvulsive status epilepticus (NCSE) in 11 (5.6%). Epileptiform abnormalities (either ictal or interictal) were present in 96 (48.7%). Preceding clinical seizures during hospitalization were associated with both electrographic seizures (36.4% in those with vs 8.1% in those without prior clinical seizures, odds ratio [OR] 6.51, p = 0.01) and NCSE (27.3% vs 4.3%, OR 8.34, p = 0.01). A pre-existing intracranial lesion on neuroimaging was associated with NCSE (14.3% vs 3.7%; OR 4.33, p = 0.02). In multivariate analysis of outcomes, electrographic seizures were an independent predictor of in-hospital mortality (hazard ratio [HR] 4.07 [1.44-11.51], p < 0.01). In competing risks analysis, hospital length of stay increased in the presence of NCSE (30 day proportion discharged with vs without NCSE: HR 0.21 [0.03-0.33] vs 0.43 [0.36-0.49]). INTERPRETATION: This multicenter retrospective cohort study demonstrates that seizures and other epileptiform abnormalities are common in patients with COVID-19 undergoing clinically indicated cEEG and are associated with adverse clinical outcomes. ANN NEUROL 2021;89:872-883.

Lighting Strikes Twice: Recurrent Guillain-Barré Syndrome (GBS) after Influenza Vaccination.

Guillain-Barré syndrome (GBS) is a rare acute demyelinating syndrome of the peripheral nervous system that is commonly preceded by infection. Vaccinations have also been associated with an increased incidence of GBS, though the risk is low. Caution with revaccination is recommended in patients with a history of GBS. Risks of revaccination compared with the risks of influenza complications should be considered. Patients who experience GBS after vaccination have not been shown to have an increased incidence of recurrent GBS after the influenza vaccine, though evidence is limited. We report a case of recurrent GBS in a patient following the influenza vaccine.

Acute Symptomatic Seizures in Critically Ill Patients with COVID-19: Is There an Association?

BACKGROUND: The coronavirus disease of 2019 (COVID-19) emerged as a global pandemic. Historically, the group of human coronaviruses can also affect the central nervous system leading to neurological symptoms; however, the causative mechanisms of the neurological manifestations of COVID-19 disease are not well known. Seizures have not been directly reported as a part of COVID-19 outside of patients with previously known brain injury or epilepsy. We report two cases of acute symptomatic seizures, in non-epileptic patients, associated with severe COVID-19 disease. CASE PRESENTATIONS: Two advanced-age, non-epileptic, male patients presented to our northeast Ohio-based health system with concern for infection in Mid-March 2020. Both had a history of lung disease and during their hospitalization tested positive for SARS-CoV-2. They developed acute encephalopathy days into their hospitalization with clinical and electrographic seizures. Resolution of seizures was achieved with levetiracetam. DISCUSSION: Patients with COVID-19 disease are at an elevated risk for seizures, and the mechanism of these seizures is likely multifactorial. Clinical (motor) seizures may not be readily detected in this population due to the expansive utilization of sedatives and paralytics for respiratory optimization strategies. Many of these patients are also not electrographically monitored for seizures due to limited resources, multifactorial risk for acute encephalopathy, and the risk of cross-contamination. Previously, several neurological symptoms were seen in patients with more advanced COVID-19 disease, and these were thought to be secondary to multi-system organ failure and/or disseminated intravascular coagulopathy-related brain injury. However, these patients may also have an advanced breakdown of the blood-brain barrier precipitated by pro-inflammatory cytokine reactions. The neurotropic effect and neuroinvasiveness of SARS-Coronavirus-2 have not been directly established. CONCLUSIONS: Acute symptomatic seizures are possible in patients with COVID-19 disease. These seizures are likely multifactorial in origin, including cortical irritation due to blood-brain barrier breakdown, precipitated by the cytokine reaction as a part of the viral infection. Patients with clinical signs of seizures or otherwise unexplained encephalopathy may benefit from electroencephalography monitoring and/or empiric anti-epileptic therapy. Further studies are needed to elucidate the risk of seizures and benefit of monitoring in this population.

Satisfaction with Care and Satisfaction with Decision Making are Similar Regardless of Staffing Model in a Neurocritical Care Unit.

INTRODUCTION: Patient-centered care, particularly shared medical decision making, is difficult to measure in critically ill patients where decisions are often made by a designated surrogate, often receiving information from multiple providers with varying degrees of training. The purpose of this study was to compare short-term satisfaction with care and decision making in patients or surrogates between two neurocritical care units [one staffed by a neurocritical care attending and advanced practice providers (APPs) and one staffed by a neurocritical care attending and resident/fellow trainees] using the Family Satisfaction in the ICU (FS-ICU) survey. METHODS: Over a 6-month period, the FS-ICU was administered on a tablet device to patients or surrogates at least 24 h after admission and stored on REDCap database. RESULTS: One hundred and thirty-four patients or surrogates completed the FS-ICU. The response rates were 59.97% and 46.58% in the APP and trainee units, respectively. There were no differences in patient age, sex, ventilator days or ICU length of stay. Overall, there were no differences in satisfaction with care or perceived shared medical making between the units. Respondents who identified their relationship with the patient as "other" (not a spouse, parent, nor a sibling) were less satisfied with care. Additionally, surrogates who identified as parents of the patient were more satisfied with degree of shared medical decision making. CONCLUSION: This study showed that: (1) collecting FS-ICU in a neurocritical care unit is feasible, (2) overall there is no difference in short-term satisfaction with care or shared decision making between a NICU staffed with trainees compared to one staffed with APPs, and (3) parents of patients have a higher short-term satisfaction with degree of shared medical decision making.

Fatal Brain Injury Following Carbon Dioxide Angiography.

INTRODUCTION: Carbon dioxide (CO2) as a contrast agent has been in use as early as the 1920s for visualization of retroperitoneal structures. Digital subtraction angiography (DSA) using CO2 as a contrast agent for vascular imaging was developed in the 1980s. Currently, CO2  angiography is an alternative agent in patients with chronic kidney disease (CKD) and those who are at risk of developing contrast-induced nephropathy. However, CO2 causes neurotoxicity if the gas inadvertently enters the cerebrovascular circulation leading to fatal brain injury. CASE PRESENTATION: A 71-year-old female with h/o sickle cell trait, hypertension, obesity, metastatic renal cell cancer status post nephrectomy, bone metastasis, chronic kidney disease was admitted for elective embolization of the humerus bone metastasis. Given the high probability of contrast-induced nephropathy, CO2 angiography was chosen for embolization of the metastasis. During the procedure, the patient became unresponsive. Emergent medical management with hyperventilation, 100% fraction oxygen inhalation was performed. Her neuroimaging showed global cerebral edema. An intracranial pressure monitor was placed which confirmed intracranial hypertension. Hyperosmolar therapy was administered with no improvement in clinical examination. She progressed to brain stem herniation. Given poor prognosis, the family opted for comfort measures and the patient expired. DISCUSSION AND CONCLUSIONS: Inadvertent carbon dioxide entry into cerebrovascular circulation during angiography can cause fatal brain injury. Caution must be exercised while performing CO2  angiography in blood vessels above the diaphragm.

Early detection of brainstem herniation using electroencephalography monitoring - case report.

BACKGROUND: Continuous electroencephalography (cEEG) is an important neuromonitoring tool in brain injured patients. It is commonly used for detection of seizure but can also be used to monitor changes in cerebral blood flow. One such event that can cause a change in cerebral blood flow is imminent, cerebral herniation. cEEG monitoring and quantitative electroencephalography (QEEG) can be used as neurotelemetry to detect cerebral herniation prior to onset of clinical signs. CASE PRESENTATION: We discuss two cases highlighting the use of cEEG in cerebral herniation accompanied by clinical examination changes. The first case is a patient with multiorgan failure and intracerebral hemorrhage (ICH). Given his coagulopathy status, his ICH expanded. The second case is a patient with intraventricular hemorrhage and worsening obstructive hydrocephalus. In both cases, the cEEG showed increasing regional/lateralized slowing. The Quantitative electroencephalography (QEEG) showed a decrease in frequencies, worsening asymmetry, decreasing amplitude and increasing burst suppression ratio corresponding with the ongoing herniation. Clinically, these changes on cEEG preceded the bedside neurological changes by up to 1 h. CONCLUSIONS: The use of cEEG to monitor patients at high risk for herniation syndromes may identify changes earlier than bedside clinical exam. This earlier identification may allow for an earlier opportunity to intervene.

Patient-Reported Outcomes (PROs) in Acute Symptomatic Seizure (ASyS) Versus Patients With Established Epilepsy.

PURPOSE: Acute symptomatic seizures (ASyS) are common in critically ill patients. It is unknown how ASyS affect posthospitalization self-reported health compared to patients with established epilepsy. METHODS: This is a retrospective cohort study from 2010 to 2018. Patients were identified by an institutional epilepsy database (Ebase). Patient-reported outcome measures (PROMs) were completed as part of standard of care and included the number of seizures in the prior 4 weeks, Liverpool Seizure Severity Scale (LSSS) ictal score, quality of life in epilepsy (QOLIE)-10, Patient Health Questionnaire-9 scales, and the PROM Information System Global Health (PROMIS-GH) scale. Mixed-effects models were created to adjust for age, sex, and race and to examine score trajectory over the 1 year after baseline. RESULTS: A total of 15 311 established epilepsy patients and 317 patients with ASyS were identified. When compared to patients with epilepsy, patients with ASyS were older, mostly male, more often black, and had worse baseline scores on the QOLIE-10 (P < .001), PROMIS-GH Physical Health (P = .037), and LSSS Ictal (P = .006) scales. Patient-Reported Outcomes Measurement Information System Mental and Physical Health T-scores were worse than the general population (T-score = 50) for patients with both ASyS (44 and 42.5, respectively) and epilepsy (44.2 and 44.6, respectively). After adjusting for age, sex, and race, patients with ASyS reported 38% fewer seizures (P = .006) yet worse QOLIE-10 score (P = .034). We found that scores improved over time for all PROMs except for PROMIS-GH Mental Health. CONCLUSION: Compared to patients with epilepsy, patients with ASyS had fewer seizures but worse epilepsy-specific quality of life. Independent of group status, scores generally improved over time.

Post-acute symptomatic seizure (PASS) clinic: A continuity of care model for patients impacted by continuous EEG monitoring.

OBJECTIVE: We present a model for the outpatient care of patients undergoing continuous electroencephalography (cEEG) monitoring during a hospitalization, named the post-acute symptomatic seizure (PASS) clinic. We investigated whether establishing this clinic led to improved access to epileptologist care. METHODS: As part of the PASS clinic initiative, electronic health record (EHR) provides an automated alert to the inpatient care team discharging adults on first time antiepileptic drug (AED) after undergoing cEEG monitoring. The alert explains the rationale and facilitates scheduling for a PASS clinic appointment, three-month after discharge, along with a same-day extended (75 minutes) EEG. We compared the initial epilepsy clinic visits by patients undergoing cEEG in 2017, before ("Pre-PASS" period and cohort) and after ("PASS" period and cohort) the alert went live in the EHR. RESULTS: Of the 170 patients included, 68 (40%) suffered a seizure during the mean follow-up of 20.9 ± 10 months. AEDs were stopped or reduced in 66 out of 148 (44.6%) patients discharged on AEDs. Pre-PASS cohort included 45 patients compared to 145 patients in the PASS cohort, accounting for 5.8% and 9.9% of patients, respectively, who underwent cEEG during the corresponding periods (odds ratio [OR] = 1.8, 95% CI = 1.26-2.54, P = .001). The two cohorts did not differ in terms of electrographic or clinical seizures. The PASS cohort was significantly more likely to be followed up within 1-6 months of discharge (OR = 4.6, 95% CI = 2.1-10.1, P < .001) and have a pre-clinic EEG (51.2% vs 11.1%; OR = 8.39, 95% CI = 3.1-22.67, P < .001). SIGNIFICANCE: PASS clinic, a unique outpatient transition of care model for managing patients at risk of acute symptomatic seizure led to an almost twofold increase in access to an epileptologist. Future research should address the wide knowledge gap about the best post-hospital discharge management practices for these patients.

Central Nervous System Fungal Infection-Related Stroke: A Descriptive Study of Mold and Yeast-Associated Ischemic Stroke.

OBJECTIVE: Central nervous system (CNS) ischemic events caused by fungal infections are rare, and clinical characteristics of these ischemic events are largely unknown. The objective of this manuscript is to highlight characteristics of fungal-related strokes and describe possible mechanistic differences between CNS mold and yeast infection-related strokes. METHODS: We report a single-center retrospective case series of all adult patients who presented with concurrent CNS fungal infection and stroke between 2010 and 2018. Patients believed to have a stroke etiology due to cardioembolic, atheroembolic, or strokes nontemporally associated with a CNS fungal infection and those with incomplete stroke workups were excluded from analysis. RESULTS: Fourteen patients were identified with ischemic stroke and concurrent CNS fungal infection without other known ischemic stroke etiology. Eight patients had a CNS yeast infection, and 6 had a CNS mold infection. All patients presented with recurrent or progressive stroke symptoms. Six patients were immune-compromised. Four patients admitted to intravenous drug use. All yeast infections were identified by cerebrospinal fluid culture or immunologic studies while all but one of the mold infections required identification by tissue biopsy. Leptomeningeal enhancement was only associated with CNS yeast infections, while basal ganglia stroke was only associated with CNS mold infections. CONCLUSION: Ischemic stroke secondary to CNS fungal infections should be considered in patients with recurrent or progressive cryptogenic stroke, regardless of immune status and cerebrospinal fluid profile. CNS yeast and mold infections have slightly different stroke and laboratory characteristics and should have a distinct diagnostic method. Depending on clinical suspicion, a thorough diagnostic approach including spinal fluid analysis and biopsy should be considered.

Determinants and outcome of repeat continuous electroencephalogram monitoring-A case-control study.

OBJECTIVE: A retrospective, single-center study to analyze the determinants of a repeat continuous EEG (cEEG) monitoring during hospitalization and its outcomes using a matched case-control study design. METHODS: Adults with a repeat cEEG session (cases) were matched by age (±3 years), gender, and mental status to patients with a single cEEG (controls) during hospitalization. Several clinical and EEG characteristics were analyzed to identify predictors of repeat cEEG. Repeat cEEG outcomes were analyzed based on its yield of electrographic seizure. We investigated the predictors of finding increased epileptic potential (degree of association with electrographic seizures) on the repeat cEEG, a marker for possible anti-epileptic drugs (AEDs) management change. RESULTS: A total of 213 (8.6% of all unique cEEG patients) cases were included. A multivariable conditional logistic regression model comparing cases and controls showed that the presence of acute brain insult [odds ratio (OR) = 3.36, 95% CI = 1.26-8.94, P = .015], longer hospital admission (OR = 1.11, 95% CI = 1.07-1.15, P < .001) and being on AEDs at the end of index cEEG (OR = 4.0, 95% CI = 1.8-8.87, P < .001) was determinants of a repeat cEEG. Among cases, 17 (8%) had electrographic seizures on repeat cEEG. Increased epileptic potential on repeat cEEG was noted in 34 (16%) cases. The latter is associated with change in etiology after the index cEEG (P = .03) and duration of repeat cEEG (P = .003) based on multivariable logistic regression model. AEDs were changed in 46 (21.6%) patients based on repeat cEEG findings. SIGNIFICANCE: Repeat cEEG is not an uncommon practice. It leads to the diagnosis of electrographic seizures in a significant percentage of patients. With the potential of impacting AED management in 16%-21% patients, it should be considered in high-risk patients suffering acute brain insults undergoing prolonged hospitalization.

Lateralized Periodic Discharges are Predictive of Seizures in Patients with Intracerebral Hemorrhage.

BACKGROUND: Patients with intracerebral hemorrhages (ICHs) have higher incidence of seizures. Previous studies have suggested that location and size of hemorrhage may increase epileptogenicity. We aim to evaluate seizure development risk factors from clinical examination, imaging, and continuous electroencephalography (cEEG) in critically ill patients with ICH. METHODS: We reviewed 57 consecutive patients with ICH admitted to a neurocritical intensive care unit over a 24-month period who were monitored on cEEG. Their demographic and examination data, ICH score, Glasgow Coma Scale (GCS), location of bleed, cEEG patterns, and discharge status were analyzed. RESULTS: Sixteen (28%) patients from our study cohort had seizures at a mean duration of 7.46 h from cEEG hookup. Fifteen (93%) of those patients had only electrographic seizures. The finding of lateralized periodic discharges (LPDs) was significantly (P = 0.019) associated with seizures. Other variables, such as ICH score, size and location of hemorrhage, GCS, mental status, and other cEEG patterns, were not significantly associated with seizures. CONCLUSION: We found that LPDs were predictive of seizures in ICH patients. cEEG for longer than 24 h is preferred for detection of seizures as they occurred at a mean later than 7 h and most were without clinical signs.

Electroencephalographic biomarkers of epilepsy development in patients with acute brain injury: a matched, parallel cohort study.

OBJECTIVE: This study was designed to investigate if highly epileptic electroencephalogram (EEG) findings in patients with acute brain injury increase the long-term risk of epilepsy development. METHODS: Adults patients, lacking epilepsy history, with electrographic seizures or lateralized periodic discharges (LPDs) (cases) were identified and matched based on age, mental status, and etiology with the ones lacking any epileptiform activity (controls) on continuous EEG (cEEG) during hospitalization. The primary outcome of clinical seizures after hospital discharge and their antiepileptic drug (AED) status was determined using a telephonic interview. Logistic regression models using generalized estimating equations to account for the matched nature of the data were performed. RESULTS: A total of 70 cases [16 (22.9%) "LPDs only," 34 (48.6%) "electrographic seizure only," and 20 (28.6%) "both"] and controls were enrolled. A total of 22 (31.4%) cases developed epilepsy after a mean follow-up duration of 20.6 ± 5.0 months compared to three (4.3%) controls. After adjusting for cEEG indication and follow-up duration, the odds of cases developing epilepsy were almost 15 times higher compared to the controls (OR = 14.8, 95% CI = 2.4-92.3, P = 0.004). This elevated risk was despite a 10 times higher likelihood of cases to be taking AEDs at the last follow-up (OR = 10.34, 95% CI = 3.7-29, P < 0.001). INTERPRETATION: Highly epileptic EEG findings in patients with acute brain injury may serve as prognostic biomarkers of epilepsy development. Although prospective studies are required to confirm our findings, it seems that with epilepsy developing in almost one-third cases in less than 2-year follow-up period, such patients may potentially be ideal candidates for epilepsy prevention clinical trials.

Developmental Venous Anomaly Presenting with Spontaneous Intracerebral Hemorrhage, Acute Ischemic Stroke, and Seizure.

Developmental venous anomaly (DVA) is the most common, benign, congenital vascular malformation of the brain and mostly an incidental finding on imaging. The exact etiology of DVA is unknown but thought to be due to medullary vein thrombosis during embryonic venous development. DVA is generally asymptomatic although associated neurologic deficits and seizures have been described. Several reports of DVA causing neurovascular compression, obstructive hydrocephalus, venous infarction, and intracerebral hemorrhage (ICH) have been described. In this report, we discuss a patient with fluctuating neurological symptoms found to have multiple DVA, predominantly draining into the deep venous system. To the best of our knowledge, DVAs leading to simultaneous ischemic stroke, intracerebral hemorrhage, and seizures are not reported in the literature. We reviewed the relevant literature and discussed the epidemiology and clinical and radiological characteristics of DVA.

Anti-N-methyl-D-aspartate Encephalitis Concomitantly with Tall-cell Variant Papillary Thyroid Carcinoma.

Anti-N-methyl-D-aspartate (NMDA) encephalitis is an autoimmune-mediated process characterized by psychosis, seizures, dyskinetic movements, and autonomic instability. At least half of the reported cases are paraneoplastic, particularly associated with an ovarian teratoma. None have been reported to be associated with thyroid tumor. We present a case of anti-NMDA encephalitis concomitantly occurring in setting of papillary thyroid carcinoma in a woman who presented with headaches, myalgia and somnolence mimicking meningoencephalitis. A 29-year-old African female presented with fever, headache, myalgia, somnolence and behavioral changes. Initial evaluation was significant for lymphocytic pleocytosis with normal glucose and protein. She was started on broad spectrum empiric antibiotics. Despite antibiotics, she continued to have worsening encephalopathy, hallucinations, epileptic seizures, and multifocal dyskinesias involving the face and extremities with no electroencephalogram correlate. Extensive infectious workup was unremarkable. Whole-body CT with contrast and ovarian ultrasound were unremarkable for malignancy. Serum auto-antibodies to the NMDA receptor and thyroid peroxidase were detected. She was treated with high-dose intravenous steroids, plasmapheresis, intravenous immunoglobulin, and rituximab with no clinical or serological response. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed a hypermetabolic thyroid nodule. Fine needle aspiration of the nodule revealed papillary thyroid carcinoma. She underwent total thyroidectomy and pathology showed two foci of tall-cell variant papillary thyroid carcinoma. Serological and clinical response followed shortly after tumor resection. The NMDA receptor stain of the papillary thyroid carcinoma was nonreactive. We describe the coincidentally co-occurrence of NMDA encephalitis in a patient with papillary thyroid carcinoma. This case highlights the importance of presumed cases of non-paraneoplastic NMDA encephalitis, FDG-PET may help in detecting occult malignancies.