BrainWaves Podcast

Last week we talked about caffeine, and this week we've moved onto cosmetics. But not the outward kind, the inward kind. Dr. Anjan Chatterjee joins us in this segment on how the military and other professions may leverage mind-altering substances in order to enhance performance. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. REFERENCES 1. Chatterjee A. Cosmetic neurology: The controversy over enhancing movement, mentation, and mood. Neurology. 2004;63:968-974 2. Lieberman HR, Tharion WJ, Shukitt-Hale B, Speckman KL, Tulley R. Effects of caffeine, sleep loss, and stress on cognitive performance and mood during u.S. Navy seal training. Sea-air-land. Psychopharmacology. 2002;164:250-261

Quantum (noun, pl. quanta): The amount of neurotransmitter stored within a single vesicle of a neuron. It is quantitatively the smallest amount of information that can be transmitted between nerves in the human body. We have hijacked this concept to describe the smallest amount of information we can share with you on a neurology podcast. In this series, which we have called Quanta, we'll be discussing the most fundamental neurologic principles so that our main episodes won't have to. Enjoy! BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice.

Yes! Finally an episode dedicated entirely to caffeine! And just how wonderful it is. ...and how wonderful it may not be. In this installment of BrainWaves, you'll hear about how fantastic and how frightful this chemical can be. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. Yes, caffeine can be toxic. But so is water. Be smart, do your homework, and remember this is just a podcast--not a guideline for pharmacological management. REFERENCES 1. Nawrot P, Jordan S, Eastwood J, Rotstein J, Hugenholtz A, Feeley M. Effects of caffeine on human health. Food Addit Contam. 2003;20:1-30 2. Ferre S. An update on the mechanisms of the psychostimulant effects of caffeine. J Neurochem. 2008;105:1067-1079 3. Park CA, Kang CK, Son YD, Choi EJ, Kim SH, Oh ST, et al. The effects of caffeine ingestion on cortical areas: Functional imaging study. Magn Reson Imaging. 2014;32:366-371 4. Martin ED, Buno W. Caffeine-mediated presynaptic long-term potentiation in hippocampal ca1 pyramidal neurons. J Neurophysiol. 2003;89:3029-3038 5. Ribeiro JA, Sebastiao AM. Caffeine and adenosine. J Alzheimers Dis. 2010;20 Suppl 1:S3-15 6. Pelchovitz DJ, Goldberger JJ. Caffeine and cardiac arrhythmias: A review of the evidence. The American journal of medicine. 2011;124:284-289

If you have sickle cell disease, that means you have a 1 in 10 chance of experiencing a stroke before college. And if you don't think that's going to hold you back, you don't know stroke. This week on BrainWaves, Dr. Erica Jones shares her experience with the neurologic complications of sickle cell anemia, and the latest guidelines for managing patients with this condition. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. REFERENCES 1. "Data & Statistics." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 31 Aug. 2016. Web. 04 Dec. 2016. 2. Wang WC, Dwan K.
Blood transfusion for preventing primary and secondary stroke in people with sickle cell disease. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD003146.
DOI: 10.1002/14651858.CD003146.pub2. 3. Motulsky, Arno G. "Frequency of Sickling Disorders in U.S. Blacks." New England Journal of Medicine 288.1 (1973): 31-33. Web. Dec. 2016. 4. Lionnet, F., N. Hammoudi, K. S. Stojanovic, V. Avellino, G. Grateau, R. Girot, and J.-P. Haymann. "Hemoglobin sickle cell disease complications: a clinical study of 179 cases." Haematologica 97.8 (2012): 1136-141. Web. Dec. 2016. 5. Ohene-Frempong K, Weiner SJ, Sleeper LA, Miller ST, Embury S, Moohr JW, Wethers DL, Pegelow CH, Gill FM. “Cerebrovascular accidents in sickle cell disease: rates and risk factors.” Blood. 1998;91(1):288 Dec. 2016. 6. Bang, Oh Young, Miki Fujimura, and Seung-Ki Kim. "The Pathophysiology of Moyamoya Disease: An Update." Journal of Stroke 18.1 (2016): 12-20. Web. Dec. 2016. 7. Gueguen, Antoine, Matthieu Mahevas, Ruben Nzouakou, Hassan Hosseini, Anoosha Habibi, Dora Bachir, Pierre Brugière, François Lionnet, Jean-Antoine Ribeil, Bertrand Godeau, Robert Girot, Vahid Ibrahima, David Calvet, Frédéric Galactéros, and Pablo Bartolucci. "Sickle-cell disease stroke throughout life: A retrospective study in an adult referral center." American Journal of Hematology 89.3 (2014): 267-72. Web. Dec. 2016. 8. Scott, R. Michael, and Edward R. Smith. "Moyamoya Disease and Moyamoya Syndrome." New England Journal of Medicine 360.12 (2009): 1226-237. Web. Dec. 2016. 9. Switzer, Jeffrey A., David C. Hess, Fenwick T. Nichols, and Robert J. Adams. "Pathophysiology and treatment of stroke in sickle-cell disease: present and future." The Lancet Neurology 5.6 (2006): 501-12. Web. Dec. 2016. 10. Verduzco, L. A., and D. G. Nathan. "Sickle cell disease and stroke." Blood 114.25 (2009): 5117-125. Web. Dec. 2016. 11. Ware, R. E., and R. W. Helms. "Stroke With Transfusions Changing to Hydroxyurea (SWiTCH)." Blood 119.17 (2012): 3925-932. Web. Dec. 2016. 12. Strouse, John J., Sophie Lanzkron, and Victor Urrutia. "The epidemiology, evaluation and treatment of stroke in adults with sickle cell disease." Expert Review of Hematology 4.6 (2011): 597-606. Web. Dec. 2016.

"Though this be madness, yet there is method in't." Shakespeare didn't know it, but he was already talking about thymectomy in Hamlet. In this week's BrainWaves episode, you'll hear about the pharmacologic fundamentals, and the most recent guidelines for treatment of myasthenia. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. REFERENCES 1. Schneider-Gold C, Gajdos P, Toyka KV and Hohlfeld RR. Corticosteroids for myasthenia gravis. The Cochrane database of systematic reviews. 2005:CD002828. 2. Wolfe GI, Kaminski HJ, Aban IB, Minisman G, Kuo HC, Marx A, Strobel P, Mazia C, Oger J, Cea JG, Heckmann JM, Evoli A, Nix W, Ciafaloni E, Antonini G, Witoonpanich R, King JO, Beydoun SR, Chalk CH, Barboi AC, Amato AA, Shaibani AI, Katirji B, Lecky BR, Buckley C, Vincent A, Dias-Tosta E, Yoshikawa H, Waddington-Cruz M, Pulley MT, Rivner MH, Kostera-Pruszczyk A, Pascuzzi RM, Jackson CE, Garcia Ramos GS, Verschuuren JJ, Massey JM, Kissel JT, Werneck LC, Benatar M, Barohn RJ, Tandan R, Mozaffar T, Conwit R, Odenkirchen J, Sonett JR, Jaretzki A, 3rd, Newsom-Davis J, Cutter GR and Group MS. Randomized Trial of Thymectomy in Myasthenia Gravis. The New England journal of medicine. 2016;375:511-22.

I have my own methods for conceptualizing altered mental status. But you already heard them in episode 46. This week on BrainWaves, take a wider view of this type of consult from the perspective of an internist. Dr. Fima Macheret takes the mic on this case of a young woman with seizures and encephalopathy. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. The content in this episode was approved by Dr. Fima Macheret. REFERENCES 1. Aagaard-Tillery KM and Belfort MA. Eclampsia: morbidity, mortality, and management. Clin Obstet Gynecol. 2005;48:12-23. 2. Duley L, Henderson-Smart DJ, Walker GJ and Chou D. Magnesium sulphate versus diazepam for eclampsia. The Cochrane database of systematic reviews. 2010:CD000127.

It is April 1st, 2017. Otherwise known as April Fools Day. But it doesn't have to be April 1st for you to be tricked by your neurology patient. In this week's episode of BrainWaves, we go over some of the ways to avoid being fooled the next time around. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice.

Yes, we have harnessed the power of paralysis. Botulinum toxin, which is produced by a lethal bacterium, Clostridium botulinum, has been bottled and sold to neurologists for decades. And you know this because you've seen people who received Botox to relax their facial muscles. In this week's installment, Dr. Anh-Thu Vu discusses how neurologists utilize this neurotoxic agent. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. The content in this episode was vetted and approved by Anh-Thu Vu. REFERENCES 1. Arnon SS, Schechter R, Inglesby T V, et al. Botulinum toxin as a biological weapon: medical and public health management. JAMA. 2001;285(8):1059-1070. 2. Thenganatt MA, Fahn S. Botulinum toxin for the treatment of movement disorders. Curr Neurol Neurosci Rep. 2012;12(4):399-409. doi:10.1007/s11910-012-0286-3. 3. Aurora SK, Winner P, Freeman MC, et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled analyses of the 56-week PREEMPT clinical program. Headache. 2011;51(9):1358-1373. doi:10.1111/j.1526-4610.2011.01990.x. 4. Dauer WT, Burke RE, Greene P, Fahn S. Current concepts on the clinical features, aetiology and management of idiopathic cervical dystonia. Brain. 1998;121 (Pt 4):547-560. 5. Karp BI. Botulinum toxin treatment of occupational and focal hand dystonia. Mov Disord. 2004;19 Suppl 8:S116-S119. doi:10.1002/mds.20025. 6. Elia AE, Filippini G, Calandrella D, Albanese A. Botulinum neurotoxins for post-stroke spasticity in adults: a systematic review. Mov Disord. 2009;24(6):801-812. doi:10.1002/mds.22452. 7. Naumann M, Dressler D, Hallett M, et al. Evidence-based review and assessment of botulinum neurotoxin for the treatment of secretory disorders. Toxicon. 2013;67:141-152. doi:10.1016/j.toxicon.2012.10.020. 8. Lotia M, Jankovic J. Botulinum Toxin for the Treatment of Tremor and Tics. Semin Neurol. 2016;36(1):54-63. doi:10.1055/s-0035-1571217.

Clumsiness can be hard to localize. But in a patient with a remote history of cancer, you should be suspicious for a number of things. In this week's clinical case, we discuss a patient who was cured of Hodgkins Lymphoma but returns with progressive dysmetria. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. The content in this episode was vetted and approved by Joseph Berger. REFERENCES 1. Bellizzi A, Anzivino E, Rodio DM, et al. New insights on human polyomavirus JC and pathogenesis of progressive multifocal leukoencephalopathy. Clin Dev Immunol 2013;1-17. 2. Garcia-Suarez J, de Miguel D, Krsnik I, et al. Changes in the natural history of progressive multifocal leukoencephalopathy in HIV-negative lymphoproliferative disorders: Impact of novel therapies. Am J Hematol 2005;80(4):271-81. 3. Felli V, DiSibio A, Anselmi M, et al. Progressive multifocal leukoencephalopathy following treatment with Rituximab in an HIV-negative patient with non-Hodgkin lymphoma: A case report and literature review. Neuroradiol J 2014;27(6):657-64. 4. Van Assche G, Van Ranst M, Sciot R, et al. Progressive multifocal leukoencephalopathy after natalizumab therapy for Crohn’s disease. N Engl J Med 2005;353:362-8. 5. Abate G, Corazzelli G, Ciarmiello A, et al. Neurologic complications of Hodgkin’s disease: A case history. Ann Oncol 1997;8(6):593-600. 6. Hoppe RT, Advani RH, Bierman PJ, et al. Hodgkin disease/lymphoma. Clinical practice guidelines in oncology. J Natl Compr Canc Netw 2006;4(3):210-30. 7. Pavlovic D, Patera AC, Nyberg F, et al. Progresive multifocal leukoencephalopathy: current treatment options and future perspectives 2015;8(6):255-73. 8. Cettomai D and McArthur JC. Mirtazapine use in human immunodeficiency virus-infected patients with progressive multifocal leukoencephalopathy. Arch Neurol 2009(2):255-258. 9. Alstadhaug KB, Croughs T, Henriksen S, et al. Treatment of progressive multifocal leukoencephalopathy with interleukin 7. JAMA Neurol 2014;71(8):1030-35.

I can't imagine a better way to celebrate our FIFTIETH episode than to discuss my favorite subject: Large vessel disease. Although we only cover one aspect of this stroke mechanism--atherosclerosis--and technically many of these trials may be somewhat outdated, the matter discussed in this episode remains the most up-to-date in the field. Take a listen. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. REFERENCES 1. Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, Cote R, Hess D, Saver J, Spence JD, Stern B, Wilterdink J, Therapeutics and Technology Assessment Subcommittee of the American Academy of N. Carotid endarterectomy--an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2005;65:794-801. 2. Kakkos SK, Nicolaides AN, Charalambous I, Thomas D, Giannopoulos A, Naylor AR, Geroulakos G, Abbott AL, Asymptomatic Carotid S and Risk of Stroke Study G. Predictors and clinical significance of progression or regression of asymptomatic carotid stenosis. J Vasc Surg. 2014;59:956-967 e1. 3. Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, Warlow CP, Barnett HJ and Carotid Endarterectomy Trialists C. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003;361:107-16. 4. Hosseini AA, Kandiyil N, Macsweeney ST, Altaf N and Auer DP. Carotid plaque hemorrhage on magnetic resonance imaging strongly predicts recurrent ischemia and stroke. Annals of neurology. 2013;73:774-84. 5. Lovett JK, Coull AJ and Rothwell PM. Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. Neurology. 2004;62:569-73. 6. Mantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG and Investigators C. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): stenting versus carotid endarterectomy for carotid disease. Stroke; a journal of cerebral circulation. 2010;41:S31-4. 7. Jauch EC, Saver JL, Adams HP, Jr., Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW, Jr., Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H, American Heart Association Stroke C, Council on Cardiovascular N, Council on Peripheral Vascular D and Council on Clinical C. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke; a journal of cerebral circulation. 2013;44:870-947. 8. Chambers BR and Donnan GA. Carotid endarterectomy for asymptomatic carotid stenosis. The Cochrane database of systematic reviews. 2005:CD001923.

It may look like water, but CSF is anything but. In this week's episode of BrainWaves, we discuss the contents of CSF and how to interpret them. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. REFERENCES 1. Frederiks JA and Koehler PJ. The first lumbar puncture. J Hist Neurosci. 1997;6:147-53. 2. Seehusen DA, Reeves MM and Fomin DA. Cerebrospinal fluid analysis. Am Fam Physician. 2003;68:1103-8. 3. Shah KH and Edlow JA. Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage. J Emerg Med. 2002;23:67-74. 4. Deisenhammer F, Bartos A, Egg R, Gilhus NE, Giovannoni G, Rauer S, Sellebjerg F and Force ET. Guidelines on routine cerebrospinal fluid analysis. Report from an EFNS task force. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2006;13:913-22. 5. Nagel MA, Cohrs RJ, Mahalingam R, Wellish MC, Forghani B, Schiller A, Safdieh JE, Kamenkovich E, Ostrow LW, Levy M, Greenberg B, Russman AN, Katzan I, Gardner CJ, Hausler M, Nau R, Saraya T, Wada H, Goto H, de Martino M, Ueno M, Brown WD, Terborg C and Gilden DH. The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features. Neurology. 2008;70:853-60. 6. Messacar K, Schreiner TL, Van Haren K, Yang M, Glaser CA, Tyler KL and Dominguez SR. Acute flaccid myelitis: A clinical review of US cases 2012-2015. Annals of neurology. 2016;80:326-38.

Idiopathic intracranial hypertension, also known as the pseudotumor cerebri syndrome, is characterized by elevated intracranial pressure with clinical features of headaches, vision impairment, and occasionally cranial nerve palsies in the absence of a structural lesion on neuroimaging. But that doesn't mean the neuroimaging has to be normal. See what Dr. Anita Kohli has to say about the radiographic correlates of IIH, their relevance, and their prognostic utility in this week's episode. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. REFERENCES 1. Friedman DI, Liu GT and Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology. 2013;81:1159-65. 2. Bidot S and Bruce BB. Update on the Diagnosis and Treatment of Idiopathic Intracranial Hypertension. Semin Neurol. 2015;35:527-38. 3. Agid R, Farb RI, Willinsky RA, Mikulis DJ and Tomlinson G. Idiopathic intracranial hypertension: the validity of cross-sectional neuroimaging signs. Neuroradiology. 2006;48:521-7. 4. Bidot S, Saindane AM, Peragallo JH, Bruce BB, Newman NJ and Biousse V. Brain Imaging in Idiopathic Intracranial Hypertension. J Neuroophthalmol. 2015;35:400-11. 5. Bidot S, Clough L, Saindane AM, Newman NJ, Biousse V and Bruce BB. The Optic Canal Size Is Associated With the Severity of Papilledema and Poor Visual Function in Idiopathic Intracranial Hypertension. J Neuroophthalmol. 2016;36:120-5. 6. Zagardo MT, Cail WS, Kelman SE and Rothman MI. Reversible empty sella in idiopathic intracranial hypertension: an indicator of successful therapy? AJNR American journal of neuroradiology. 1996;17:1953-6.

In 1959, Adams and colleagues described a few patients who developed a rapid flaccid quadriparesis following fluid resuscitation for malnutrition and chronic alcoholism. Twenty years later, we learned that this occurs as a consequence of rapid correction of hyponatremia. But this isn't the only cause of the osmotic demyelination syndrome... Hear Dr. Joshua VanDerWerf discuss the history and clinical relevance of this unusual critical care scenario. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. REFERENCES 1. Adams RA, Victor M, Mancall EL. Central pontine myelinolysis: a hitherto undescribed disease occurring in alcoholics and malnourished patients. Arch Neurol Psychiatry 1959;81:154–72. 2. Gocht A, Colmant HJ. Central pontine and extrapontine myelinolysis: a report of 58 cases. Clin Neuropathol. 1987 Nov-Dec;6(6):262-70. 3. Kleinschmidt-Demasters BK, Rojiani AM, Filley CM. Central and extrapontine myelinolysis: then...and now. J Neuropathol Exp Neurol. 2006 Jan;65(1):1-11. 4. Martin RJ. Central pontine and extrapontine myelinolysis: the osmotic demyelination syndromes. J Neurol Neurosurg Psychiatry. 2004;75 Suppl 3:iii22-8. 5. Menger H, Jorg J. Outcome of central pontine and extrapontine myelinolysis. J Neurol 1999;246:700–5. 6. Siegler JE, Wang AR, Vanderwerf JD. Normonatremic osmotic demyelination in the setting of acquired immune deficiency syndrome and malnutrition: case report and literature review. J Neurovirol. 2016 Jul 12. 7. Wright DG, Laureno R, Victor M. Pontine and extrapontine myelinolysis. Brain. 1979 Jun;102(2):361-85.

The request for a consult is like calling in a favor. You shouldn't actually expect the consultant to do it, you should be polite and helpful in all the ways your grandmother expects you to behave. At least that's the courtesy I've seen from really spectacular providers. In this week's episode, we not only review the proper etiquette for calling a consult, but you'll also hear some pearls on the workup for altered mental status. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. REFERENCES None this week. (Sorry!)

It may come as a surprise to you, but patients who seize...will seize. And in this week's episode, we talk about the fundamentals in working up a patient who presents in status epilepticus. So SEIZE the opportunity to learn from Dr. Chloe Hill as she navigates us through this week's Teaching through Clinical Cases. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. The content in this episode was vetted and approved by Chloe Hill. REFERENCES 1. Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, Handforth A, Faught E, Calabrese VP, Uthman BM, Ramsay RE and Mamdani MB. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. The New England journal of medicine. 1998;339:792-8. 2. Claassen J, Hirsch LJ, Emerson RG and Mayer SA. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam: a systematic review. Epilepsia. 2002;43:146-53. 3. Mayer SA, Claassen J, Lokin J, Mendelsohn F, Dennis LJ and Fitzsimmons BF. Refractory status epilepticus: frequency, risk factors, and impact on outcome. Archives of neurology. 2002;59:205-10.