Faculty Bibliography

Patients can have more than one neurological problem, and sorting out acute from chronic disease can be challenging. The authors report a middle-aged patient who presented with ataxia, right hemiparesis, and abnormal nystagmus. Magnetic resonance imaging (MRI) showed a Chiari and an arachnoid cyst with brainstem compression that appeared to explain his abnormal examination. Shortly after admission, he was noted to have intermittent abnormal behavior and confusion. History from family revealed significant acute and chronic psychiatric problems that appeared to explain his abnormal mental status; this delayed the diagnosis of intermittent complex partial seizures. The multitude of various symptoms resulted in a delay of the final diagnosis of Creutzfeldt-Jakob disease (CJD), which in retrospect explained the entire new physical examination, seizures, and mental status changes.

Anti-N-Methyl-D-Aspartate receptor encephalitis is a recently described entity (Dalmau et al. 2007, 2008) that may present with a variety of complex movements in addition to other features (Kleinig et al. 2008). The purpose of our presentation of such a patient is twofold: (1) to characterize these complex oculo-oro-linguo-masticatory and limb movements with "smooch sign" as myorhythmia, based on a combined clinical and electrophysiological analysis (Masucci et al. 1984); and (2) to document possibly characteristic EEG evolution in the course of observation in our institution for three weeks from diffuse slowing to evolving rhythmic delta activity, which may represent a pattern of electrographic seizure activity.

Vagal nerve stimulation (VNS) has been reported to adversely impact breathing in sleep. While continuous positive airway pressure is often employed to treat these patients, little data exist on the effects of adjusting various settings on VNS-induced sleep-disordered breathing. We describe a patient in whom increasing off-time caused resolution of VNS-induced arterial oxygen desaturations in sleep, which we believe is a novel observation.

Much confusion still exists about when to treat seizures related to stroke and what agents to use. Seizures may occur in the setting of ischemic stroke, intracranial hemorrhage, subarachnoid hemorrhage, and other cerebrovascular lesions. The epidemiology of poststroke seizures and patients at higher risk for developing poststroke epilepsy are identified. The utility of electroencephalography (EEG), continuous and video EEG monitoring, and management and treatment of those patients who develop epilepsy are discussed.

Driving for the person with epilepsy (PWE) remains an important issue. Requirements for reporting PWE to driving authorities vary across the United States. We studied the prior experiences of PWE regarding counseling for driving in a reporting state (37% in New Jersey) and a nonreporting state (52% in Arizona). A prospective voluntary anonymous survey was conducted among patients with new-onset epilepsy at two epilepsy referral centers. Subjects were queried about prior interactions with health care professionals regarding attitudes toward and knowledge of driving regulations. Practitioners caring for PWE are in the position to provide advice and counsel regarding driving regulations. Fifty percent or fewer subjects were appropriately counseled, regardless of residence requirements. PWE felt they were honest with their physician and 10% of subjects have driven against medical advice. A performance gap exists in the appropriate counseling regarding driving for PWE that has potentially significant safety and legal implications.