FDG-PET and MRI in the Evolution of New-Onset Refractory Status Epilepticus.

BACKGROUND AND PURPOSE: New-onset refractory status epilepticus is a clinical condition characterized by acute and prolonged pharmacoresistant seizures without a pre-existing relevant neurologic disorder, prior epilepsy, or clear structural, toxic, or metabolic cause. New-onset refractory status epilepticus is often associated with antineuronal antibodies and may respond to early immunosuppressive therapy, reflecting an inflammatory element of the condition. FDG-PET is a useful diagnostic tool in inflammatory and noninflammatory encephalitis. We report here FDG-PET findings in new-onset refractory status epilepticus and their correlation to disease activity, other imaging findings, and outcomes. MATERIALS AND METHODS: Twelve patients who met the criteria for new-onset refractory status epilepticus and who had FDG-PET and MR imaging scans and electroencephalography at a single academic medical center between 2008 and 2017 were retrospectively identified. Images were independently reviewed by 2 radiologists specialized in nuclear imaging. Clinical characteristics and outcome measures were collected through chart review. RESULTS: Twelve patients underwent 21 FDG-PET scans and 50 MR imaging scans. Nine (75%) patients were positive for autoantibodies. All patients had identifiable abnormalities on the initial FDG-PET in the form of hypermetabolism (83%) and/or hypometabolism (42%). Eight (67%) had medial temporal involvement. All patients (n = 3) with N-methyl-D-aspartic acid receptor antibodies had profound bilateral occipital hypometabolism. Initial MR imaging findings were normal in 6 (50%) patients. Most patients had some degree of persistent hyper- (73%) or hypometabolism (45%) after immunosuppressive therapy. FDG-PET hypometabolism was predictive of poor outcome (mRS 4-6) at hospital discharge (P = .028). CONCLUSIONS: Both FDG-PET hypometabolism and hypermetabolism are seen in the setting of new-onset refractory status epilepticus and may represent markers of disease activity.

The Safety and Effectiveness of Intravenous Lacosamide for Refractory Status Epilepticus in the Critically Ill.

BACKGROUND: Status epilepticus (SE) often does not respond to initial treatment. A second-line agent with a less established safety and efficacy profile is then required. This study examined the safety of intravenous (IV) lacosamide (LCM) in a critically ill population and obtained an estimate of effectiveness in patients with refractory SE on continuous video EEG monitoring (cEEG). METHODS: Retrospective review of critically ill patients in SE on cEEG treated with IV LCM from June 2009 to April 2011. RESULTS: Eighty-four patients in SE (43 F/41 M), mean age 59.6 years, were identified; and 59.5 % had nonconvulsive SE. The most common etiologies were ischemic and hemorrhagic strokes. There were no significant changes in serial blood pressure monitoring, PR prolongation, aspartate aminotransferase (AST), or creatinine pre- and post-LCM. There was a significant increase in alanine aminotransferase (ALT) from days 1-7 (p = 0.031). Fifty-one patients were LCM-naïve. In these patients, cessation of SE on cEEG after LCM occurred in 15.7, 25.5, 58.8, and 82.4 % by 4, 12, 24, and 48 h, respectively. CONCLUSION: IV LCM appears safe short term in critically ill patients with SE. The retrospective estimate of effectiveness for LCM appears promising for management in SE. Prospective, randomized controlled studies are needed to better determine the role of LCM in treating SE.

[(18)F]-Fluoro-Deoxy-Glucose Positron Emission Tomography Scan Should Be Obtained Early in Cases of Autoimmune Encephalitis.

Introduction. Autoimmune encephalitis (AE) is a clinically challenging diagnosis with nonspecific neurological symptoms. Prompt diagnosis is important and often relies on neuroimaging. We present a case series of AE highlighting the importance of an early [(18)F]-fluoro-deoxy-glucose positron emission tomography (FDG-PET) scan. Methods. Retrospective review of seven consecutive cases of autoimmune encephalitis. Results. All patients had both magnetic resonance imaging (MRI) and FDG-PET scans. Initial clinical presentations included altered mental status and/or new onset seizures. Six cases had serum voltage-gated potassium channel (VGKC) antibody and one had serum N-methyl-D-aspartate (NMDA) antibody. MRI of brain showed mesial temporal lobe hyperintensity in five cases of VGKC. The other two patients with VGKC or NMDA AE had restiform body hyperintensity on MRI brain or a normal MRI, respectively. Mesial temporal lobe hypermetabolism was noted in three cases on FDG-PET, despite initial unremarkable MRI. Malignancy workup was negative in all patients. Conclusion. A high index of suspicion for AE should be maintained in patients presenting with cognitive symptoms, seizures, and limbic changes on neuroimaging. In cases with normal initial brain MRI, FDG-PET can be positive. Additionally, extralimbic hyperintensity on MRI may also be observed.

Continuous electroencephalography (cEEG) changes precede clinical changes in a case of progressive cerebral edema.

BACKGROUND: Continuous electroencephalogram (cEEG) is tightly linked to cerebral metabolism and is sensitive to cerebral ischemia and hypoxia. The severity of cerebral ischemia can be seen on cEEG as changes in morphology, amplitude, or frequency, and cEEG may detect neuronal dysfunction at a reversible stage. METHODS: Case report and imaging. RESULTS: We present a case of focal cerebral edema with changes seen on cEEG 24 h before clinical signs of increased intracranial pressure. cEEG showed developing asymmetry in the left hemisphere followed by burst suppression. The right hemisphere showed similar progression to burst suppression. Complete suppression of both hemispheres was noted 6 h before clinical signs of herniation. Computed tomography (CT) head confirmed a large left parietal intracerebral hematoma with mass effect. CONCLUSIONS: cEEG has applications in monitoring cerebral dysfunction in addition to detecting seizure activity in the intensive care unit. It may serve a vital role in multi-modality monitoring for early recognition of neurological complications from brain injuries that may not be noticed clinically, which is paramount to early intervention.

Structural characterization of novel L-galactose-containing oligosaccharide subunits of jojoba seed xyloglucans.

Jojoba seed xyloglucan was shown to be a convenient source of biologically active xyloglucan oligosaccharides that contain both L- and D-galactosyl residues [E. Zablackis et al., Science, 272 (1996) 1808-1810]. Oligosaccharides were isolated by liquid chromatography of the mixture of oligosaccharides generated by treating jojoba seed xyloglucan with a beta-(1-->4)-endoglucanase. The purified oligosaccharides were reduced with NaBH4, converting them to oligoglycosyl alditol derivatives that were structurally characterized by a combination of mass spectrometry and 2-dimensional NMR spectroscopy. This analysis established that jojoba xyloglucan oligosaccharides contain the novel side-chain [alpha-L-Gal p-(1-->2)-beta-D-Galp-(1-->2)-alpha-D-Xyl p-(1-->6)-], which is structurally homologous to the fucose-containing side-chain [alpha-L-Fucp-(1-->2)-beta-D-Galp-(1-->2)-alpha-D-Xyl p-(1-->6)-] found in other biologically active xyloglucan oligosaccharides.

Substitution of L-fucose by L-galactose in cell walls of Arabidopsis mur1.

An Arabidopsis thaliana mutant (mur1) has less than 2 percent of the normal amounts of L-fucose in the primary cell walls of aerial portions of the plant. The survival of mur1 plants challenged the hypothesis that fucose is a required component of biologically active oligosaccharides derived from cell wall xyloglucan. However, the replacement of L-fucose (that is, 6-deoxy-L-galactose) by L-galactose does not detectably alter the biological activity of the oligosaccharides derived from xyloglucan. Thus, essential structural and conformational features of xyloglucan and xyloglucan-derived oligosaccharides are retained when L-galactose replaces L-fucose.