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Background and ObjectivesSM is recognized as a complication of migraine in which pain and/or associated symptoms are unremitting and debilitating for more than 72 hours. The epidemiology of SM in the general population is not known. The aim of this study is to determine the incidence, recurrence rate, and clinical associations of status migrainosus (SM) in care-seeking residents of Olmsted County, Minnesota.MethodsThe Rochester Epidemiology Project was used to identify the incident cases of SM according to theInternational Classification of Headache Disorders, Third Editioncriteria and based on the first physician-encountered case in the record. The clinical characteristics of the incident cases were abstracted from the medical record. One-year recurrence-free survival was evaluated and compared between clinically relevant groups, including baseline demographics, migraine characteristics, and treatment exposures.ResultsBetween January 1, 2012, and December 31, 2017, 237 incident cases of SM were identified. The median age was 35 (IQR 26–47) years, and 210 (88.6%) were female. A history of chronic migraine was recorded in 82/226 (36.3%) and a history of aura in 76/213 (35.7%). At the time of the incident case, medication reconciliation included a triptan or ergotamine in 127/233 (53.6%) and/or an opioid-containing analgesic in 43/233 (18.5%). The overall age- and sex-adjusted incidence rate was 26.60 per 100,000 [95% CI, 23.21–29.97], with a peak incidence between ages 40 and 49 years. The median (95% CI) attack duration was 5 (4.48–5.42) days. The most frequent triggers were stress (40/237, 16.9%) and too much or too little sleep (27/237, 11.4%). Recurrence occurred in 35/237 (14.8%) at a median of 58 (IQR 23–130) days following the initial attack. In our age- and sex-adjusted multivariable model, too much or too little sleep as a trigger was associated with 12-month risk of recurrence (adjusted OR 3.59 [95% CI 1.58–8.14],p= 0.0022).DiscussionOur study provides a population-based estimate of SM incidence. We identified aberrant sleep patterns as a potentially modifiable risk factor for 1-year SM recurrence.

ObjectiveTo examine the clinical outcomes of intentional overdoses involving triptans and ergotamines with a retrospective review of the National Poison Data System (NPDS).MethodsThis was a 5-year retrospective cross-sectional study (2014–2018) using the NPDS. Demographics, exposure characteristics, and outcomes were described. Univariate logistic regression was used to estimate the odds ratio (OR) for major effect or death. A multivariable logistic regression model with inclusion criteria of p < 0.1 in univariate analysis was implemented with backwards selection.ResultsIn this population (n = 1,489), multiple exposure was most common (n = 1,145). The mean age was 31.2 years and 1,197 (80.4%) participants were female. Major effects from a single exposure were seen in p = 0.004), multiple product exposure (OR 9.50; 95% CI 2.29–39.48; p = 0.002), and concomitant overdose with benzodiazepines (OR 1.71; 95% CI 1.05–2.78; p = 0.032) or tricyclic antidepressants (OR 3.16; 95% CI 1.88–5.31; p < 0.001).ConclusionThe risk of major effect or death was low and predicted by age, multiple product exposure, and concomitant benzodiazepine or tricyclic antidepressant. The triptan toxidrome consists of hypertension, tachycardia, and drowsiness. The toxic effects of ergotamine are acute gastrointestinal syndrome with vertigo and numbness. No cases of serotonin syndrome were seen.

Garcia-Azorin et al.1 report on their detailed and cross-sectional appraisal of delayed alcohol-induced headache in approximately 1,100 university students. Their detailed phenotyping substantially deepens and expands our understanding of this common secondary headache syndrome.

Elevation in serum carcinoembryonic antigen (CEA) is uncommon in the context of primary CNS neoplasms but can be seen with metastatic brain tumors. CEA elevation can be the presenting feature of a secretory meningioma (SM), a rare subtype of WHO grade I meningioma.

ObjectiveTo evaluate an observational-behavioral pain tool among individuals with acute poststroke aphasia.MethodsWe performed a randomized, double-blind, controlled study of experimental pain assessment among 36 adult patients with acute poststroke aphasia. Patients were administered 3 levels of mechanical pain, including placebo. The behavioral responses were video recorded and then evaluated by 3 neurology nurses using the Pain Assessment Checklist for Seniors With Limited Ability to Communicate (PACSLAC-II). Pain-specific facial action units were quantified with FaceReader version 6.1.ResultsMedian PACSLAC-II ratings for 0-, 2-, and 4.5-lb weight stimuli were 2 (0, 3), 1 (0, 3), and 2 (1, 5), respectively. Overall, differences were not detected (p = 0.06). Pairwise comparisons with the Wilcoxon method demonstrated significance in differentiating PACSLAC-II ratings of patients experiencing the 4.5-lb stimulus vs either the 2-lb weight (p = 0.03) or placebo (p = 0.05). Overall interrater reliability by the Cronbach α was strong at 0.87, 0.94, and 0.96 for weights of 0, 2, and 4.5 lb, respectively. Pain-specific facial activation and negative valence were observed similarly in placebo and experimental pain groups.ConclusionsAmong our cohort with acute poststroke aphasia, the PACSLAC-II was not able to overall differentiate patients experiencing experimental mechanical pain, although differences in those experiencing the strongest pain stimulus were significant. The detection of pain-specific facial activation and negative valence in the placebo group indicates that pain and distress are unmet needs among stroke patients who are unable to verbally communicate.

Objectives: As residency programs adjust to new duty hour restrictions, the use of cross-coverage systems requiring handoffs will rise. Handoffs are vulnerable to communication failures when unstructured. Accordingly, we implemented a standardized sign-out process on our inpatient neurology services and assessed its effect on completeness and perceived accuracy of handoffs. Methods: Residents spent the first half of their rotations utilizing unstructured sign-out. They transitioned to a structured sign-out system (using the situation-background-assessment-recommendation format) during the second half of their rotations. We analyzed survey responses before and after implementation to evaluate for an effect. Results: Residents utilizing structured sign-out were significantly more likely to share test results with patients/families prior to shift changes ( p = 0.037), update our electronic service list ( p = 0.045), and feel all important data were being transmitted ( p = 0.041). Overall satisfaction (scale 1–10) increased from 6.2 ± 1.6 to 7.4 ± 1.3 ( p = 0.002). Conclusions: Our findings demonstrate that standardized sign-out improves the completeness and perceived accuracy of handoffs. Such improvement has the potential to improve patient safety and quality of care.

1. An orbital bruit represents increased blood flow through the collateral arterial system and intracranial arterial supply. In the correct clinical context, the presence of an orbital bruit should make the examiner suspect either a severe stenosis or occlusion of either the ipsilateral or the contralateral internal carotid artery (ICA). 2. Orbital bruits can represent compensated perfusion to the contralateral hemisphere. This occurs as flow velocity increases through the ipsilateral ICA and through the anterior communicating artery. Thus, blood flow moves from the asymptomatic side to the occluded vascular territory. 3. When listening for an orbital bruit, auscultate by placing the bell of the stethoscope over the patient’s closed eye. In an effort to eliminate the noise of rhythmic eyelid flutter, the patient should then be instructed to open both eyes and gaze at a point across the room. If necessary, the eyelid can be passively shut using the bell of the stethoscope. 4. Although not featured on many popular stethoscopes, a deep and narrow bell (i.e., the Ford-Bowles stethoscope) is ideal for the purpose of ocular and arterial auscultation. Orbital bruits are also found in systemic illness (severe anemia, thyrotoxicosis) and vascular anomaly (carotid-cavernous fistula, arterial vascular malformation). An 83-year-old right-handed man presented with increasing episodes of right limb shaking over a 9-month period. Each episode lasted several …

edited by Jose Biller, 748 pp., Lippincott Williams & Wilkins, 2012, $99.99 Similar to prior editions, this is a paperback organized into 2 major sections, devoted to diagnosis and treatment, respectively. The format of the book makes it cumbersome at times to locate desired information, often making the reader dependent on the index in the back. For example, if you want to read about the diagnosis of peripheral neuropathy, it is not intuitive whether to jump to the chapter on gait disturbances, lower extremity pain, or acute sensory loss in the diagnosis section. It turns out that the entire discussion of peripheral neuropathy diagnosis is in the treatment section.

edited by David Borsook, Arne May, Peter J. Goadsby, and Richard Hargreaves, 384pp., Oxford University Press, 2012, $145. The Migraine Brain is an expertly authored and edited compendium of insights into human migraine pathophysiology. While the focus is on neuroimaging, there is an appropriate homage to other research perspectives from both animal models and genetic studies. Part 1 is a single-chapter historical perspective on migraine from antiquity through selected 20th century observations. Part 2 provides a concise pathophysiologic review of selected clinical observations, including proposed mechanisms of photophobia, allodynia, and the transition from episodic to chronic headache. Part 3 is labeled a clinical perspective, consisting of somewhat disjointed chapters ranging from a review of migraine prophylactic treatments to a review of the literature on iron accumulation in the migraine brain. Highlights of this section include timely clinical perspectives on both neuroimaging and genetic testing. Part 4 constitutes the heart of the text, with individual chapters devoted to reviews of both interictal and ictal imaging findings as organized by technique. Part 5 concludes the book with perspectives on future directions of neuroimaging research.

Objective: To highlight the utility of magnetic resonance gradient echo (MR GRE) in the early diagnosis of primary angiitis of the central nervous system (PACNS) through a case report. Background PACNS is a rare form of vasculitis. The presenting symptoms of PACNS are often nonspecific, including encephalopathy, headaches, stroke, seizures, and cranial nerve palsies. Currently, biopsy is the gold standard for diagnosing PACNS. The sensitivity and specificity of less invasive testing, including conventional MRI, magnetic resonance angiography (MRA), CSF analysis, and four vessel angiography, are not as robust. Design/Methods: Case-report and literature review. Results: : A 52 year old gentleman presented for workup of episodic vertigo, dysphasia, and headaches. MRI brain revealed confluent subcortical T2 signal hyperintensities in the right frontotemporal and left temporal regions, corresponding small punctuate and linear zones of contrast enhancement, and a subacute left cerebellar hemorrhage. His MR GRE imaging revealed subcortical microhemorrhages and a left cerebellar hemorrhage. Serologic workup revealed normal CBC, electrolytes, INR, sedimentation rate, lactate dehydrogenase, angiotensin-converting enzyme level, myeloperoxidase, proteinase, antiphospholipid, and paraneoplastic antibodies. CSF examination revealed prominent lymphocytosis and negative cytology. MRA and conventional angiography were unrevealing. A cortical biopsy revealed chronic perivascular lymphocytic inflammation with focal granulomatous features and negative beta amyloid stain suggestive of PACNS. The patient was treated with a five day course of intravenous methylprednisolone (1 gram daily), followed by an oral prednisone taper. He reported no further episodes of vertigo or semantic paraphasia following initiation of steroids. Conclusions: Our case demonstrates the utility of GRE in the early diagnosis of PACNS. The presence of cortical and/or subcortical signal hypointensities on GRE (consistent with petechial hemorrhages) can help to distinguish PACNS from many of its mimickers. Such an imaging modality may be useful for promptly establishing the diagnosis and treating with immunosuppression, which is needed to avoid significant morbidity and mortality. Disclosure: Dr. Toledano has nothing to disclose. Dr. Smith has nothing to disclose. Dr. Dhamija has nothing to disclose. Dr. Jones has nothing to disclose. Dr. Moseley has nothing to disclose.

A 43-year-old man presented for neurologic evaluation with acute bilateral hearing loss. Two weeks before presentation, he had bilateral eye pain diagnosed as scleritis. He also noted a subacute history of fevers, night …