Neurological Causes Research Articles

Case report of uniocular diplopia in a 26-year-old female: A diagnostic dilemma

A 26-year-old female had complaints of left eye monocular diplopia, blurred, wavy vision for 4 months and was diagnosed and managed as Dry eye syndrome outside. She did not improve clinically and presented to us. Routine ophthalmologic evaluations, including keratometry, slit lamp biomicroscopy, and fundoscopy, were done to rule out anterior and posterior segment etiologies. MRI brain and visual fields were done to rule out neurological causes. Provisional diagnosis of unilateral anisometropic amblyopia was made. On LASIK evaluation, she was found to have keratoconus suspect in corneal topography, and diagnosis of posterior keratoconus was confirmed with higher diagnostic tests like optical coherence tomography anterior segment and corneal tomography. She was managed with Cretan plus protocol. One must have a higher index of suspicion toward corneal ectatic disorders in this particular type of symptomatology of young patients.

Obstructive sleep apnea induced bilateral tonic- clonic seizure of unknown origin: A case series of a novel association

BackgroundObstructive sleep apnea is a highly prevalent disorder, characterized by recurrent events of upper airway obstruction during sleep and associated with recurrent cycles of desaturation and re-oxygenation, sympathetic hyperactivity, and intra-thoracic pressure fluctuations, resulting in fragmentation of sleep and subsequent daytime fatigue with excessive sleepiness. Obstructive sleep apnea-induced bilateral tonic–clonic seizures are unheard of. We aimed to report 3 patients with previously undiagnosed obstructive sleep apnea who presented to the emergency department with new onset bilateral tonic–clonic seizure without any evidential neurological or metabolic cause. MethodsPatient data were obtained from medical records from the Department of Internal Medicine, IPGMER and SSKM Hospital, Kolkata, and Belle Vue Clinic, Kolkata, India. ResultsThree male patients (67, 58, and 44 years old) presented with bilateral tonic–clonic seizure disorder without any underlying cause of seizures after rigorous investigations except for moderate to severe obstructive sleep apnea on polysomnography. All 2 patients were seizure-free after being treated with levetiracetam, chronic continuous positive airway pressure therapy in 2, and only continuous positive airway pressure in the other. The patients remained seizure-free on continuous positive airway pressure, even when levetiracetam was withdrawn, suggesting obstructive sleep apnea's causality in their new-onset acute seizures. ConclusionAlthough further investigation is required to clarify this association, underlying obstructive sleep apnea should be ruled out in patients with a first-ever bilateral tonic–clonic seizure. Whether or not continuous positive airway pressure alone could effectively treat hypoxia and deranged cortical excitability, which may lead to seizures in cases with long-standing obstructive sleep apnea, is yet to be explored.

Causes of Visual Impairment and Types of Low Vision Aids Prescribed in Low Vision Clinic, Sibu Hospital, Sarawak

This study was to determine the causes of visual impairment and to identify the low vision prescribing pattern among Low Vision Clinic (LVC) patients in the Sibu Hospital. This study was conducted retrospectively among 41 patients attending the LVC, Sibu Hospital. Patients’ demographic characteristics, causes of low vision and blindness, and types of low vision devices prescribed were recorded and analysed for 21 (52.5%) males and 19 (47.5%) females. The mean age was 39.38 ± 17.98 years. The main causes of visual impairment were retinal dystrophies in 12 cases (30.0%) followed by neurological causes in 9 cases (22.5%), glaucoma in 8 cases (20.0%), and acquired macular disorders in 4 cases (10.0%). A total of 27 low vision devices were dispensed, 85.2% (n = 23) were near devices and 14.8% (n = 4) were distance devices. The most frequently prescribed low vision devices (LVD) were video magnifiers (37.0%), followed by hand magnifiers (22.2%), spectacle magnifiers (14.8%), telescopes (14.8%) and stand magnifiers (11.1%). The main leading causes of visual impairment in LVC Sibu Hospital were retinal dystrophies. Video magnifiers were the most common type of low-vision device prescribed. A prompt comprehensive screening is urged for family members with retinal dystrophies to detect the diseases early and hence timely exposure to low vision care and rehabilitation. Familial counselling on inherited retinal diseases and better screening by primary eye care providers are required. Low vision services should be an integral part of the eye care systems in Malaysia.

B-069 Performance Evaluation of a Ma2 Autoantibodies ELISA

Abstract Background Ma-2 is a neuronal nucleolar protein with purported involvement in RNA transcription and apoptosis regulation. Patients with Ma2 antibodies present with autoimmune encephalitis (limbic or brainstem). Ma-2 antibodies are a high-risk marker for paraneoplastic neurologic cause for autoimmune encephalitis (>75% of patients having either testicular cancer or non-small cell lung cancer). In older patients, there is a higher frequency of small cell lung cancer or other cancers especially when Ma 1 antibodies are also detected. Identification of Ma2 antibodies is important to help diagnose autoimmune encephalitis, guide the cancer search and aid treatment selection. The objective of this study was to develop and document the performance of a qualitative enzymatically amplified sandwich-type Ma2 Antibody ELISA. Methods The Ma2 ELISA was produced in-house utilizing commercially available protein and was performed on a Hamilton Star liquid handling instrument equipped with a plate washer and plate reader. Each assay plate included patient samples along with 3 independent negative serum calibrators and 4 quality controls (Both positive and negative controls per matrix [CSF or serum]) each tested in duplicate. Mean optical densities (OD) for patient specimens were compared to the average OD of the negative serum calibrators to generate a ratio. A ratio cut-off of 8 was selected for reporting positivity based on preliminary studies and was validated during the method performance assessment. To assess assay performance we measured precision (3 positive pools at or above the cut-off ratio for each specimen type were tested 20 times in one assay and in duplicate across 10 independent assays), accuracy comparing to the current reference method at Athena® Diagnostics (N = 10 positives / 40 negatives), analytical specificity (20 samples with high titer autoantibodies directed against other proteins), and the impact of common interferences (lipids, bilirubin, hemolysate were spiked into 2 positive and 1 negative sample per interference). Clinical performance of the assay for differentiating healthy donors without disease (N = 140) and those with non-Ma2 neurological autoimmunity (N = 23) from those with clinical phenotypes consistent with Ma-2 associated encephalitis (N = 8) was measured. Results Serum intra-assay imprecision (coefficient of variation; %CV) ranged from 3.0–6.5%. Inter-assay imprecision ranged from 21–29%. CSF intra-assay imprecision ranged from 3.5–10%. Inter-assay imprecision ranged from 13–15.5%. Accuracy was assessed via qualitative comparison to a reference method [western blot or nanoliter scale immunoassay]. There was perfect agreement between methods. To assess analytical specificity, samples with high concentrations of immunoglobulins (hypergammaglobulinemia [N = 10] or Systemic Lupus Erythematosus [N = 10]) were tested in serum (and spiked into CSF); all were negative. Interference studies were conducted on 2 positive Ma2 serum and CSF samples, spiked for highly hemolytic (1000 mg/dL), lipemic (2000 mg/dL) and icteric (60 mg/dL) conditions. All samples remained positive under given interferents. A negative sample was tested for each matrix, both remained negative. Clinical specificity was 100% with all samples from patients without Ma-2 encephalitis testing negative (N = 183). All ELISA positives identified in this study had phenotypes consistent with Ma-2 autoimmune encephalitis (N = 8). Conclusion The performance of the Ma2 ELISA was acceptable for clinical laboratory implementation.

Revisiting anti-Hu paraneoplastic autoimmunity: phenotypic characterization and cancer diagnosis.

Anti-Hu are the most frequent antibodies in paraneoplastic neurological syndromes, mainly associated with an often limited stage small cell lung cancer. The clinical presentation is pleomorphic, frequently multifocal. Although the predominant phenotypes are well characterized, how different neurological syndromes associate is unclear. Likewise, no specific study assessed the performance of new-generation CT and PET scanners for cancer screening in these patients. Herein, we aimed to describe the clinical pattern and cancer screening in a retrospective cohort of 466 patients with anti-Hu autoimmunity from the French Reference Centre on Paraneoplastic Neurological Syndromes registry. Clinical presentation, cancer screening and diagnosis were analysed. Among the 466 patients, 220 (54%) had multifocal neurological involvement. A hierarchical cluster analysis grouped the patients into (i) mainly limbic encephalitis, (ii) predominantly peripheral neuropathy and (iii) broad involvement of the nervous system (mixed group). Compared with limbic encephalitis and mixed groups, patients in the neuropathy group more frequently had a chronic onset of symptoms (29 versus 13 and 17%), elevated CSF proteins (83 versus 47 and 67%) and died from cancer progression (67 versus 15 and 28%; all P < 0.05). No significant difference in overall survival was observed between groups. Dysautonomia and brainstem signs were associated with a higher risk of death from the neurological cause; cancer diagnosis was the main predictor of all-cause death, especially when diagnosed within 2 years from clinical onset (all P < 0.05). Three hundred and forty-nine (75%) patients had cancer: in 295 (84%) neurological symptoms preceded tumour diagnosis, being lung cancer in 262 (89%), thereof small cell lung cancer in 227 (87%). First CT scan revealed lung cancer in 205/241 (85%), and PET scan shortened the interval to diagnosis when the initial CT scan was negative [7 months (1-66) in 27 patients versus 14 months (2-45) in 6; P < 0.001]. Although cancer diagnosis mostly occurred within 2 years from clinical onset, 13/295 (4%) patients exceeded that threshold. Conversely, 33 patients (7%) were 'cancer-free' after 2 years of follow-up. However, 13/33 (39%) had initial suspicious imaging findings that spontaneously regressed. In conclusion, although anti-Hu autoimmunity clinical presentation is mostly multifocal, we observed patients with a predominant limbic syndrome or isolated sensory neuropathy. Early implementation of PET scan shortens the interval to cancer diagnosis, which was the strongest predictor of death, especially if diagnosed ≤2 years from clinical onset. As cancer was diagnosed >2 years after clinical onset in few patients, screening should be extended up to 5 years. In addition, tumour regression was suspected in a substantial proportion of 'cancer-free' patients.

Diabetic Mononeuritis: Isolated Extrinsic Paralysis of the III

Oculomotor paralysis is a rare complication of diabetes. It is a rare form of diabetic neuropathy, with a prevalence of 1 to 14% in diabetics. This is a 52-year-old patient with no known personal history, who presented himself in ophthalmological consultation for left ocular pain and fall of the upper left eyelid, occurred 6 days ago and rapidly progressive in an atraumatic context. Objective ophthalmological examination a moderate left ptosis, with incomplete ophthalmoplegia sparing abduction and twists, without vicious attitude. Visual acuity at a distance without correction was 6/10 in both eyes, P3. At bio microscopy, RPM kept bilaterally, without surface disturbance with normal anterior and posterior segments. This was an incomplete paralysis of the extrinsic component of the III. Emergency radiological checkup ruled out a central vascular and neurological cause. The etiological biological assessment finds fasting blood glucose high at 1.92 g/l. It is sent to the diabetologist for investigations. The degenerative assessment is normal but with a glycated hemoglobin at 10.5%, testifying to an unknown diabetic. It is retained the diagnosis of a paralysis of III incomplete inaugural type 2 diabetes. The evolution after 2 months was marked by the progressive regression of its paralysis after glycemic balance and correction of risk factors. Oculomotor paralysis is not uncommon during diabetes, it is necessary to think about it during etiological assessment for early and adapted management.

Vertigo and dizziness in children: When to consider a neurological cause

Vertigo is common in childhood and adolescence. Although children and adults share common causes of vertigo, epidemiology changes with aging. For instance, ischemic stroke is less frequent in childhood, whereas audiovestibular disorders, such as vestibular neuritis and the migraine equivalent, are the leading causes of vertigo. However, even if severe causes of vertigo are rare, clinicians must not miss them. In this review, we discuss the neurological causes of central vertigo in children. The diagnostic approaches reviewed here are focused on the search for signs of severity, such as an abrupt onset, infectious context, or intracranial hypertension, which may subsequently require brain imaging.

Long-term low-dose tolvaptan efficacy and safety in SIADH

PurposeTolvaptan, a selective vasopressin V2-receptor antagonist, is approved for the treatment of SIADH-related hyponatremia, but its use is limited. The starting dose is usually 15 mg/day, but recent clinical experience suggests a lower starting dose (<15 mg/day) to reduce the risk of sodium overcorrection. However, long-term low-dose efficacy and safety has not been explored, so far. Aim of our study is to characterize safety and efficacy of long-term SIADH treatment with low-dose Tolvaptan.MethodsWe retrospectively evaluated 11 patients receiving low-dose Tolvaptan (<15 mg/day) for chronic SIADH due to neurological, idiopathic and neoplastic causes. Plasma sodium levels were measured before and 1, 3, 5, 15 and 30 days after starting Tolvaptan and then at 3-month intervals. Anamnestic and clinical data were collected.ResultsMean time spanned 27.3 ± 29.8 months (range 6 months-7 years). Mean plasma sodium levels were within normal range 1, 3 and 6 months after starting Tolvaptan as well as after 1, 2, 3, 5 and 7 years of therapy. Neither osmotic demyelination syndrome nor overcorrection were observed. Plasma sodium levels normalization was associated with beneficial clinical effects. Neurological patients obtained seizures disappearance, improvement in neurological picture and good recovery from rehabilitation. Neoplastic patients were able to start chemotherapy and improved their general condition. Patients did not show hypernatremia during long-term follow-up and reported mild thirst and pollakiuria.ConclusionsThe present study shows that long-term low-dose Tolvaptan is safe and effective in SIADH treatment. No cases of overcorrection were documented and mild side effects were reported.

How the Mind Creates the Body and What Can Go Wrong: Case Studies of Misperceptions of the Body.

The review brings together a wealth of case studies, both from the authors' patients and from the literature, about people whose bodies do not feel as they really should. Body parts suddenly become longer or shorter, heavier or lighter and there may be a loss of body control to the point where individuals feel as if they no longer have a body at all. The article differentiates by type of causes: mental disorders (e.g., psychosis), the influence of drugs on body perception and neurological causes. Depending on the type of body change, examples are given from the categories of sexually toned changes in body perception, out-of-body experiences and near-death experiences. Since there are countless types of body image disorders, the article is limited to a selective selection of the most interesting and sometimes obscure deviations.

Acute Obstructive Hydrocephalus: An Unexpected Cause of Cardiac Arrest

BackgroundEmergency physicians are well-versed in managing cardiac arrests, including the diagnostic and therapeutic steps after return of spontaneous circulation. Neurologic emergencies are a common cause of out-of-hospital cardiac arrest and must remain high in the differential diagnosis, as such cases often require specific interventions that may deviate from more common care pathways. Performing a noncontrast head computed tomography (NCHCT) scan after cardiac arrest has been found to change management, although the optimal timing of this imaging is unclear. Case ReportThis is the case of a young, pregnant woman who presented to the emergency department after cardiac arrest with return of spontaneous circulation in the prehospital setting. She was found to have acute obstructive hydrocephalus on NCHCT, which was later confirmed to be due to a previously undiagnosed colloid cyst of the third ventricle. This acute obstruction resulted in myocardial stunning and, ultimately, cardiac arrest. Although outcomes are often dismal when the cause of arrest is secondary to neurologic catastrophe, this patient survived with completely intact neurologic function. Why Should an Emergency Physician Be Aware of This?Although acute obstructive hydrocephalus due to a colloid cyst adjacent to the third ventricle is a rare condition, it is a potentially reversible neurologic cause of out-of-hospital cardiac arrest. However, positive outcomes depend on obtaining the diagnosis rapidly with neurologic imaging and advocating for neurosurgical intervention. This case supports the recommendation that emergency physicians should strongly consider post–cardiac arrest neurologic imaging when another cause is not immediately obvious.

Can Facial Paralysis be a Rare Complication of Hypertension?

Facial paralysis is a disorder that can result from a wide spectrum of etiologies including traumatic, infectious, congenital, neurologic, systemic, neoplastic, and iatrogenic causes. It has significant functional, psychological, and social consequences. The most common cause of fascial nerve paralysis is idiopathic facial nerve palsy (Bell’s palsy). There is a relationship between facial nerve paralysis and severe systemic hypertension. In this report we present a 43-year-old female patient with fascial paralysis who had a history of hypertension.

Problem of headache: A cross-sectional study

ABSTRACT Objectives: To assess the medical students, interns, general practitioners, and family physicians’ perception of neurological and otolaryngeal causes of headaches. Materials and Methods: A prospective, qualitative, questionnaire-based cross-sectional study took place. Five hundred and seventy-one senior medical students, interns, general practitioners (GPs), and family physicians from different geographical regions in Saudi Arabia were involved in the study. An online questionnaire is used to estimate the respondents’ knowledge regarding neurological and otolaryngeal causes of headaches. The obtained data were statistically analyzed using SPSS version 21. Results: Five hundred and seventy-one participants were involved in the study. They were 377 females and 194 males with a female-to-male ratio of 1.9:1. Most of them were medical students (69.9%). However, medical interns, general practitioners, and family physicians’ respondents were (17.3%), (7.5%), and (5.3%), respectively. They constituted different geographical regions of Saudi Arabia. An average level of knowledge about headaches was recorded in (55%) of the participants, while (42.7%) had a good level of knowledge about its etiologies. Conclusions: A considerable percentage of the current study population has average knowledge about neurological and otolaryngeal factors of headache. It is advocated that the current national medical curriculum be thoroughly reviewed and clear referral pathways must be established to have better management of these cases.

(064) Trigger Point Release of Post Partum Pudendal Compression Relieves Persistent Genital Arousal: Case Report

Abstract Introduction There is very little literature available on Persistent Genital Arousal Disorder (PGAD). Recent consensus definitions have emerged from the ISSWSH working group on PGAD to expel the myth that PGAD is merely in the minds of those who suffer from it. Dr. Goldstein, et al have published research and criteria for diagnosis, and management of this condition which can be a very distressing one. Novel Non-Invasive treatment modalities are needed for the management of PGAD to prevent distress, and/or unnecessary surgery, in these patients. Objectives To determine if local trigger point treatment of the area surrounding the Pudendal Nerve as it passes the piriformis muscle, will cause relief of Persistent Genital Arousal Disorder (PGAD) in a patient suffering for the 8 months since childbirth. Methods I present a case of a new mother who suffered from severe PGAD emerging following a precipitous and somewhat traumatic childbirth. The persistent arousal was distracting, upsetting, intolerable, and only somewhat (10-20%) temporarily mitigated by very regular self-stimulation, and also with regular pelvic floor physio, in a busy new mom, who had had no such concerns before-hand. She presented to me at 8 months post-partum, with an 8 month history of PGAD. Based on history of presenting illness, the source of problem was determined to be most likely in pelvis, and potentially caused by entrapment/compression of the Pudendal Nerve. Informed Consent was obtained to attempt trigger point release of the tissues surrounding the Pudendal Nerve posteriorly, as it enters the pelvis. Using a posterior approach, using a 27g 1.5cm bevelled needle, to an area cleaned by alcohol swab, micro-dissection release was performed of area surrounding tissue the Pudendal N as it passes the piriformis muscle. Patient reported immediate and sustained relief of symptoms. Results Trigger point needling to the tissue superior to, surrounding, and including the piriformis muscle via the posterior approach caused immediate and sustained relief of the patient’s symptoms. Repeat needle treatment to this area, alternating with physiotherapy for guided relaxation and release of surrounding tissues, resolved patient’s PGAD symptoms by &amp;gt;95% during treatment and &amp;gt;85% 1 year after treatment cessation. Conclusions Trigger Point needle treatment of tissues of the muscles and piriformis muscles relieved PGAD symptoms initially caused by Pudendal Nerve entrapment/compression second to precipitous childbirth. This non-invasive approach for immediate and sustained relief of Persistent Genital Arousal Disorder should be widely taught to practitioners of Sexual Medicine, and considered in patients with neurological causes for their distressing symptoms, arising from the pelvic area. Disclosure No.

Yield of Neurodiagnostic Testing in Children Presenting to a Pediatric Emergency Department With Altered Mental Status

Background: Emergency department (ED) visits for altered mental status (AMS) in children are common. Neuroimaging is often performed to ascertain etiology, but its utility has not been well studied. Our objective is to describe the yield of neuroimaging studies in children who present to an ED with AMS. Methods: We performed a retrospective chart review of children 0-18 years of age, presenting to our PED between 2018 and 2021 with AMS. We abstracted patient demographics, physical examination, neuroimaging and EEG results, and final diagnosis. Neuroimaging and EEG studies were classified as normal or abnormal. Abnormal studies were categorized as clinically important and contributory: abnormalities that were clinically important and contributed to the etiology, clinically important but noncontributory: abnormalities that were clinically significant but did not explain the etiology, and incidental: abnormalities that were not clinically significant. Results: We analyzed 371 patients. The most common etiology of AMS was toxicologic (188, 51%) with neurologic causes (n = 50, 13.5%) accounting for a minority. Neuroimaging was performed in one-half (169, 45.5%) and abnormalities were noted in 44 (26%) studies. Abnormalities were clinically important and contributed to the etiologic diagnosis of AMS in 15/169 (8.9%), clinically important and noncontributory in 18/169 (10.7%), and incidental in 11/169 (6.5%). EEG was performed in 65 patients (17.5%), of which 17 (26%) were abnormal with only one being clinically important and contributory. Conclusions: Though neuroimaging was performed in approximately one half of the cohort, it was contributory in a minority. Similarly, diagnostic utility of EEG in children with AMS was low.

The Brain and Long COVID: Millions of people are still suffering long after infection. Now researchers are finding neurological causes for their symptoms.

The Brain and Long COVID: Millions of people are still suffering long after infection. Now researchers are finding neurological causes for their symptoms.

Role of neurofilament light chain to reduce diagnosis and improve outcomes for patients in a real‐world cognitive neuropsychiatry service: A retrospective MiND study

AbstractBackgroundIt is common for patients presenting with neuropsychiatric symptoms to endure significant diagnostic odyssey. Neurofilament light chain (NfL) has shown promise in being able to differentiate between neurodegenerative and psychiatric disorders. This study aimed to assess the clinical utility of NfL in avoiding misdiagnosis.MethodIn this retrospective study, we conducted file review of patients assessed at Neuropsychiatry, Royal Melbourne Hospital between 2009 to 2020. We included all patients (n = 212) who had a CSF NfL level at their baseline assessment. Investigators blinded to NfL levels extracted clinical information including diagnoses from the initial and follow‐up assessments using documentation available. In addition, we collected follow‐up data from external services where available. Initial and follow‐up/final diagnoses were categorised as neurodegenerative disorder (ND), psychiatric disorder (PSY), mild cognitive impairment (MCI), unclear, and not‐neurodegenerative (Not‐ND). Not‐ND were individuals who did not meet the diagnosis for PSY or MCI, and did not have worsening symptoms. Based on our previous findings, we defined an NfL&gt;582pg/mL as a positive test result for ND.ResultSo far, we have collected information from 135 patients. Of these, 14/89 (16%) patients initially diagnosed with ND were re‐diagnosed as PSY or Not‐ND. 2/30 (7%) patients initially diagnosed with PSY were re‐diagnosed as having ND. Including MCI and unclear, 32/135 (24%) had a delayed diagnosis, which could have been reduced to 14% based on baseline CSF NfL predicting ND or Not‐ND/MC/PSY. Data analysis is ongoing and full results will be presented at the conference.ConclusionBaseline CSF NfL could have aided clinicians in a real‐world clinical setting, to reduce misdiagnosis, and increase diagnostic accuracy from 76% to 86%. An elevated level could prompt assertive investigations for neurological and neurodegenerative causes. Conversely, a low NfL, could reassure against a neurodegenerative disorder, preventing unnecessary assessments. Timely and accurate diagnosis will improve outcomes and precision care for patients and families.

A rare cause of recurrent syncope: chemodectoma of left carotid

Syncope is a frequent cause of access to emergency departments. Recurrent syncope may be associated with a transient lock of consciousness. When neurological or cardiological common causes of syncope are excluded, rare causes of syncope, such as solid carotid tumors, should be considered. In this study, we report a rare case of left carotid chemodectoma in a patient with frequent access to the emergency room for syncope in which a thorough differential diagnosis has been performed.

Causes of Death in Patients With Brain Metastases.

Advances in targeted therapies and wider application of stereotactic radiosurgery (SRS) have redefined outcomes of patients with brain metastases. Under modern treatment paradigms, there remains limited characterization of which aspects of disease drive demise and in what frequencies. This study aims to characterize the primary causes of terminal decline and evaluate differences in underlying intracranial tumor dynamics in patients with metastatic brain cancer. These fundamental details may help guide management, patient counseling, and research priorities. Using NYUMets-Brain-the largest, longitudinal, real-world, open data set of patients with brain metastases-patients treated at New York University Langone Health between 2012 and 2021 with SRS were evaluated. A review of electronic health records allowed for the determination of a primary cause of death in patients who died during the study period. Causes were classified in mutually exclusive, but collectively exhaustive, categories. Multilevel models evaluated for differences in dynamics of intracranial tumors, including changes in volume and number. Of 439 patients with end-of-life data, 73.1% died secondary to systemic disease, 10.3% died secondary to central nervous system (CNS) disease, and 16.6% died because of other causes. CNS deaths were driven by acute increases in intracranial pressure (11%), development of focal neurological deficits (18%), treatment-resistant seizures (11%), and global decline driven by increased intracranial tumor burden (60%). Rate of influx of new intracranial tumors was almost twice as high in patients who died compared with those who survived ( P < .001), but there was no difference in rates of volume change per intracranial tumor ( P = .95). Most patients with brain metastases die secondary to systemic disease progression. For patients who die because of neurological disease, tumor dynamics and cause of death mechanisms indicate that the primary driver of decline for many may be unchecked systemic disease with unrelenting spread of new tumors to the CNS rather than failure of local growth control.

1001 A Case of Unusual Nocturnal Movements Consistent with Paroxysmal Hypnogenic Dyskinesia

Abstract Introduction Paroxysmal hypnogenic dyskinesia (PHD) is a rare subset of paroxysmal dyskinesias characterized by recurring involuntary dystonic or choreoathetoid movements that occur during sleep or immediately after an arousal from sleep. These episodes often occur without loss of consciousness or trigger and lack association with epileptiform electroencephalography (EEG) activity. Report of case(s) A 61-year-old male with obstructive sleep apnea compliant with PAP was referred for abnormal nighttime movements for the past 9 years. The episodes were characterized by stereotyped involuntary dystonic posturing involving his upper extremities or his entire body lasting up to 15 seconds. The onset of the events occurred invariable during nighttime sleep and resulted in awakenings from sleep. He denied dream enactment as well as other symptoms suggestive of sleep-related movement disorders or parasomnias. Sleep deprived EEG demonstrated left temporal slowing during wakefulness and drowsiness and captured a typical event that occurred during NREM stage II sleep and had no ictal correlate. An MRI of the brain was unremarkable. During overnight polysomnogram, his current PAP settings were found to be effective, and three episodes of body stiffening consistent with his typical events were captured. These episodes were found to occur after awakening from REM sleep and lasted less than 10 seconds each. There was no EEG correlate, and REM atonia was preserved throughout. The patient was started on oxcarbazepine for the nocturnal movements, which reduced the frequency of events from 12 to 4 events per night. Oxcarbazepine was tapered and discontinued due to side effects and incomplete control of the events. Genetic testing for epilepsy syndromes is pending. Conclusion PHD is a rare syndrome of involuntary movements which begin during sleep or cause awakenings from sleep and can be misdiagnosed as a sleep disorder. It is crucial for the sleep physician to be aware of possible neurological causes of sleep-related movement disorders. Furthermore, our patient’s partial response to oxcarbazepine may further support that PHD may have an epileptic origin although not well characterized. Support (if any) Advancing Innovation in Residency Education (AIRE) Pilot Program Training Grant

A pragmatic approach of Parkinson disease detection using hybrid case-based reasoning neuro-fuzzy classification system over Mobile edge computing

Parkinson’s disease is neurological degenerative disorder cause by deficient dopamine production which in turn harms the motor functionality and speech. With latest IoT advancement in the health care era, we propose intelligent and smart Parkinson’s disease detection system based on voice signal analysis. Addition to PDs detection, we propose remote health monitoring feature that keep on monitoring and diagnosing PD person activity. To perform all tasks efficiently we divide our propose model in three phases: monitoring, diagnosing and analysis. During monitoring phase, PDs person voice signal is monitored and captured via IoT sensor enabled Smartphone device. This voices signal is further processed for PD detection over MEC server during diagnosing phase. We use Tunable Q factor wavelet transform (TQWT) for extracting feature from voice sample, these extracted feature are reduced FRS methods. For feature reduction PCA and LDA are used. Theses processed feature are then applied to hybrid case-based reasoning neuro-fuzzy (ANFIS) classification system to detect Parkinson’s disease. On the detection of PDs abnormality, the proposed healthcare monitoring system immediately generates notification to the patient simultaneously send detection report to centralized healthcare cloud system. This PDs detection report is further analyzed and stored at cloud server during analysis phase where report is analyzed by professional health expert and send the appropriate treatment and medication to PD infected person or care taker. For experimentation and performance evaluation benchmark baseline UCI dataset of PDs are used. We analyzed our proposed hybrid ANFIS-CBR classifier with existing classifiers over the accuracy, sensitivity and specificity parameter. Based on the result analysis, it is observed that proposed hybrid classifier maximum accuracy, sensitivity, and specificity of 98.23%, 99.1%, and 95.3% in comparison to other classifier.