BrainWaves Podcast

Once heralded as "benign" essential tremor, this movement disorder is anything but. And you can see this when you talk with your neurology patients about the difficulties they encounter with dressing, eating, and even speaking. Not to mention the social stigmata and cognitive dysfunction. In this BrainWaves episode, we start by describing the fundamentals of tremor and move on to the clinical features, pharmacology, and prognosis of ET. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. REFERENCES 1. Deuschl G, Raethjen J, Hellriegel H and Elble R. Treatment of patients with essential tremor. The Lancet Neurology. 2011;10:148-61. 2. Louis ED. Diagnosis and Management of Tremor. Continuum (Minneap Minn). 2016;22:1143-58. 3. Sandvik U, Koskinen LO, Lundquist A and Blomstedt P. Thalamic and subthalamic deep brain stimulation for essential tremor: where is the optimal target? Neurosurgery. 2012;70:840-5; discussion 845-6. 4. Zesiewicz TA, Elble R, Louis ED, Hauser RA, Sullivan KL, Dewey RB, Jr., Ondo WG, Gronseth GS, Weiner WJ and Quality Standards Subcommittee of the American Academy of N. Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2005;64:2008-20.

From the "gilded age" to the "germ theory", Dr. Joshua VanDerWerf (physician, historian, humanitarian), illustrates the birth of American neurology. You may recognize the names Chiari, Wernicke, and Broca, but what about William Alexander Hammond or Silas Weir Mitchell? These figures, among others, and their contributions to neurology are the subject of this week's BrainWaves 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. Goetz CG, Chmura TA, Lanska D. Part 1: the history of 19th century neurology and the American Neurological Association. Ann Neurol. 2003;53 Suppl 4:S2-S26. 2. Koehler PJ1, Lanska DJ. Mitchell's influence on European studies of peripheral nerve injuries during World War I. J Hist Neurosci. 2004 Dec;13(4):326-35. 3. Lanska DJ1. Characteristics and lasting contributions of 19th-century American neurologists. J Hist Neurosci. 2001 Aug;10(2):202-16.

Heavy metal poisoning is increasingly rare in the US, but in patients with multi-organ dysfunction and unclear exposure history, you should be suspicious. In this episode of BrainWaves, we discuss the most common metals associated with central and peripheral nerve dysfunction, the symptoms they produce, imaging features, and treatment. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. This episode was vetted and approved by Francis DeRoos. REFERENCES 1. Staff NP and Windebank AJ. Peripheral neuropathy due to vitamin deficiency, toxins, and medications. Continuum (Minneap Minn). 2014;20:1293-306. 2. Cao Y, Skaug MA, Andersen O and Aaseth J. Chelation therapy in intoxications with mercury, lead and copper. J Trace Elem Med Biol. 2015;31:188-92. 3. Sun TW, Xu QY, Zhang XJ, Wu Q, Liu ZS, Kan QC, Sun CY and Wang L. Management of thallium poisoning in patients with delayed hospital admission. Clin Toxicol (Phila). 2012;50:65-9.

There's more to epilepsy than AED titration. (Shocking, I know.) Especially in women, management is undeniably complex. For example, the same enzymatic machinery used to metabolize AEDs is also used to break down estrogen-containing oral contraceptives--an interaction that could literally open a Pandora's box of complications. These and other issues affecting the management of women with epilepsy are addressed by Dr. Danielle Becker in this week's BrainWaves podcast. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. This episode was vetted and approved by Danielle Becker. REFERENCES 1. Meador K, Reynolds MW, Crean S, Fahrbach K and Probst C. Pregnancy outcomes in women with epilepsy: a systematic review and meta-analysis of published pregnancy registries and cohorts. Epilepsy Res. 2008;81:1-13. 2. Meador KJ, Baker GA, Browning N, Cohen MJ, Bromley RL, Clayton-Smith J, Kalayjian LA, Kanner A, Liporace JD, Pennell PB, Privitera M, Loring DW and Neurodevelopmental Effects of Antiepileptic Drugs Study G. Breastfeeding in children of women taking antiepileptic drugs: cognitive outcomes at age 6 years. JAMA Pediatr. 2014;168:729-36. 3. Veliskova J and Desantis KA. Sex and hormonal influences on seizures and epilepsy. Horm Behav. 2013;63:267-77. 4. Herzog AG, Fowler KM, Smithson SD, Kalayjian LA, Heck CN, Sperling MR, Liporace JD, Harden CL, Dworetzky BA, Pennell PB, Massaro JM and Progesterone Trial Study G. Progesterone vs placebo therapy for women with epilepsy: A randomized clinical trial. Neurology. 2012;78:1959-66. 5. Tauboll E, Sveberg L and Svalheim S. Interactions between hormones and epilepsy. Seizure. 2015;28:3-11. 6. Crawford P. Best practice guidelines for the management of women with epilepsy. Epilepsia. 2005;46 Suppl 9:117-24. 7. Reiter SF, Bjork MH, Daltveit AK, Veiby G, Kolstad E, Engelsen BA and Gilhus NE. Life satisfaction in women with epilepsy during and after pregnancy. Epilepsy Behav. 2016;62:251-257. 8. Harden CL, Hopp J, Ting TY, Pennell PB, French JA, Hauser WA, Wiebe S, Gronseth GS, Thurman D, Meador KJ, Koppel BS, Kaplan PW, Robinson JN, Gidal B, Hovinga CA, Wilner AN, Vazquez B, Holmes L, Krumholz A, Finnell R, Le Guen C, American Academy of N and American Epilepsy S. Practice parameter update: management issues for women with epilepsy--focus on pregnancy (an evidence-based review): obstetrical complications and change in seizure frequency: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society. Neurology. 2009;73:126-32.

Abnormal eye movements can be...abnormal. We have already briefly covered efferent dysfunction in an earlier episode ("#9 Teaching through clinical cases: Painless ophthalmoparesis"), but now Dr. Ali Hamedani is back and excited to discuss how we characterize and localize nystagmus in the central nervous system. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. This episode was vetted and approved by Robert Avery. REFERENCES Liu GT, Volpe NJ, and Galetta SL. Neuro-ophthalmology: Diagnosis and management, 2nd ed., pp. 587-610. Elsevier, 2010.

In this week's episode of Teaching through Clinical Cases, Dr. Michael Rubenstein (episode 17, "The FAME clinic in Tanzania") leads a discussion on the evaluation of a young patient with a rapidly progressive gait difficulty with numbness and paresthesias. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. This episode was vetted and approved by Michael Rubenstein. REFERENCES 1. Kumar N, Elliott MA, Hoyer JD, Harper CM, Jr., Ahlskog JE and Phyliky RL. "Myelodysplasia," myeloneuropathy, and copper deficiency. Mayo Clinic proceedings. 2005;80:943-6. 2. Stabler SP. Vitamin B12 deficiency. The New England journal of medicine. 2013;368:2041-2. 3. Goodman BP. Metabolic and toxic causes of myelopathy. Continuum (Minneap Minn). 2015;21:84-99. 4. Kriegstein AR, Shungu DC, Millar WS, Armitage BA, Brust JC, Chillrud S, Goldman J and Lynch T. Leukoencephalopathy and raised brain lactate from heroin vapor inhalation ("chasing the dragon"). Neurology. 1999;53:1765-73. 5. Pema PJ, Horak HA and Wyatt RH. Myelopathy caused by nitrous oxide toxicity. AJNR American journal of neuroradiology. 1998;19:894-6.

A relatively recent discovery in the history of neurology, autoimmune and paraneoplastic encephalitides encompass a wide spectrum of immunologic phenomena that affect the nervous system. In this episode, which focuses on limbic encephalitis, Dr. Ramani Balu outlines his experience with these unusual conditions. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. The content in this episode was vetted and approved by Ramani Balu. REFERENCES 1. Anderson NE and Barber PA. Limbic encephalitis - a review. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2008;15:961-71. 2. Schmitt SE, Pargeon K, Frechette ES, Hirsch LJ, Dalmau J and Friedman D. Extreme delta brush: a unique EEG pattern in adults with anti-NMDA receptor encephalitis. Neurology. 2012;79:1094-100. 3. Lancaster E, Martinez-Hernandez E and Dalmau J. Encephalitis and antibodies to synaptic and neuronal cell surface proteins. Neurology. 2011;77:179-89. 4. Rosenfeld MR and Dalmau JO. Paraneoplastic disorders of the CNS and autoimmune synaptic encephalitis. Continuum (Minneap Minn). 2012;18:366-83. 5. Titulaer MJ, McCracken L, Gabilondo I, Armangue T, Glaser C, Iizuka T, Honig LS, Benseler SM, Kawachi I, Martinez-Hernandez E, Aguilar E, Gresa-Arribas N, Ryan-Florance N, Torrents A, Saiz A, Rosenfeld MR, Balice-Gordon R, Graus F and Dalmau J. Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: an observational cohort study. The Lancet Neurology. 2013;12:157-65. 6. Irani SR, Michell AW, Lang B, Pettingill P, Waters P, Johnson MR, Schott JM, Armstrong RJ, A SZ, Bleasel A, Somerville ER, Smith SM and Vincent A. Faciobrachial dystonic seizures precede Lgi1 antibody limbic encephalitis. Annals of neurology. 2011;69:892-900.

Posterior reversible encephalopathy syndrome: Not always posterior, or reversible, or with associated encephalopathy. These and other clinical and neuroimaging factoids are reviewed in this week's edition of BrainWaves where we discuss the various--and often disparate--features of PRES. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. The content in this episode was vetted and approved by Amy Pruitt. REFERENCES 1. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, Pessin MS, Lamy C, Mas JL and Caplan LR. A reversible posterior leukoencephalopathy syndrome. The New England journal of medicine. 1996;334:494-500. 2. Casey SO, Sampaio RC, Michel E and Truwit CL. Posterior reversible encephalopathy syndrome: utility of fluid-attenuated inversion recovery MR imaging in the detection of cortical and subcortical lesions. AJNR American journal of neuroradiology. 2000;21:1199-206. 3. Fugate JE and Rabinstein AA. Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions. The Lancet Neurology. 2015;14:914-25. 4. Bartynski WS. Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. AJNR American journal of neuroradiology. 2008;29:1043-9. 5. Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR American journal of neuroradiology. 2008;29:1036-42. 6. Hefzy HM, Bartynski WS, Boardman JF and Lacomis D. Hemorrhage in posterior reversible encephalopathy syndrome: imaging and clinical features. AJNR American journal of neuroradiology. 2009;30:1371-9.

A patent foramen ovale (PFO) may increase your risk of stroke, but does surgical correction reverse this risk? These and other important questions about secondary stroke prevention in patients with PFO are addressed in this week's BrainWaves podcast starring Dr. Christopher Favilla. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. The content in this episode was approved and vetted by Steven Messe. REFERENCES 1. Di Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S. Patent foramen ovale as a risk factor for cryptogenic stroke. Annals of internal medicine. 1992;117:461-465. 2. Kent DM, Dahabreh IJ, Ruthazer R, Furlan AJ, Reisman M, Carroll JD, et al. Device closure of patent foramen ovale after stroke: Pooled analysis of completed randomized trials. Journal of the American College of Cardiology. 2016;67:907-917. 3. Carroll JD, Saver JL, Thaler DE, Smalling RW, Berry S, MacDonald LA, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. The New England journal of medicine. 2013;368:1092-1100.

Rio is front and center of the world right now, not just because of the 2016 Olympic games, but also because it harbors the Zika virus. In this episode, infectious disease specialist Dr. Jennifer McGuire speaks with Dr. Ana Cristancho about the things every neurologist needs to know about this worldwide outbreak. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. The content in this episode was approved and vetted by Jennifer McGuire. REFERENCES 1. Bogoch, II, Brady OJ, Kraemer MU, German M, Creatore MI, Kulkarni MA, Brownstein JS, Mekaru SR, Hay SI, Groot E, Watts A and Khan K. Anticipating the international spread of Zika virus from Brazil. Lancet. 2016;387:335-6. 2. Campos GS, Bandeira AC and Sardi SI. Zika Virus Outbreak, Bahia, Brazil. Emerg Infect Dis. 2015;21:1885-6. 3. Duffy MR, Chen TH, Hancock WT, Powers AM, Kool JL, Lanciotti RS, Pretrick M, Marfel M, Holzbauer S, Dubray C, Guillaumot L, Griggs A, Bel M, Lambert AJ, Laven J, Kosoy O, Panella A, Biggerstaff BJ, Fischer M and Hayes EB. Zika virus outbreak on Yap Island, Federated States of Micronesia. The New England journal of medicine. 2009;360:2536-43. 4. Hayes EB. Zika virus outside Africa. Emerg Infect Dis. 2009;15:1347-50. 5. Mlakar J, Korva M, Tul N, Popovic M, Poljsak-Prijatelj M, Mraz J, Kolenc M, Resman Rus K, Vesnaver Vipotnik T, Fabjan Vodusek V, Vizjak A, Pizem J, Petrovec M and Avsic Zupanc T. Zika Virus Associated with Microcephaly. The New England journal of medicine. 2016;374:951-8.

With so many disease modifying therapies out there, how do you decide which drug to use in your MS patient? BrainWaves makes it simple. In this interview with Dr. Christopher Perrone, we review the US FDA-approved therapies for relapsing-remitting MS, their mechanisms of action, side effects, and benefits. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. The content in this episode was approved and vetted by Salim Chahin. REFERENCES 1. Wingerchuk DM and Carter JL. Multiple sclerosis: current and emerging disease-modifying therapies and treatment strategies. Mayo Clinic proceedings. 2014;89:225-40. 2. Torkildsen O, Myhr KM and Bo L. Disease-modifying treatments for multiple sclerosis - a review of approved medications. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2016;23 Suppl 1:18-27.

The human body only has enough thiamine to last 2-3 weeks, so what happens when we run out? In this BrainWaves brief, we review the consequences of acute thiamine deficiency on the nervous system. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. The content in this episode was approved and vetted by Michael Rubenstein. REFERENCES 1. Caine D, Halliday GM, Kril JJ and Harper CG. Operational criteria for the classification of chronic alcoholics: identification of Wernicke's encephalopathy. Journal of neurology, neurosurgery, and psychiatry. 1997;62:51-60. 2. Sechi G and Serra A. Wernicke's encephalopathy: new clinical settings and recent advances in diagnosis and management. The Lancet Neurology. 2007;6:442-55. 3. Zuccoli G and Pipitone N. Neuroimaging findings in acute Wernicke's encephalopathy: review of the literature. AJR Am J Roentgenol. 2009;192:501-8. 4. Galvin R, Brathen G, Ivashynka A, Hillbom M, Tanasescu R, Leone MA and Efns. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2010;17:1408-18.

How much can a picture mean to a patient? How much can it mean to a provider? And what if that picture is an MRI, instead of a photograph? In this episode of our Humanities section, we deliver 2 perspectives on imaging in patient care. On the one hand, MRI and CT scan can tell you a lot about a patient's medical history and active medical disease. On the other, a personal photograph may illuminate the social history in a way words may fail to capture. The content in this episode was approved and vetted by Salim Chahin. BrainWaves podcasts and online content are intended for medical education purposes only and should not be used for routine clinical decision making.

Myasthenia gravis is a disorder characterized by proximal weakness, ptosis, and antibody formation against proteins at the neuromuscular junction. Most commonly, the protein targeted by antibodies is the nicotinic acetylcholine receptor. However, research in the last 2 decades has identified a number of other antibody targets, which we have reviewed here in this BrainWaves brief. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. The content in this episode was vetted and approved by Grant T. Liu. REFERENCES 1. Gilhus NE and Verschuuren JJ. Myasthenia gravis: subgroup classification and therapeutic strategies. The Lancet Neurology. 2015;14:1023-36. 2. Hurst RL and Gooch CL. Muscle-Specific Receptor Tyrosine Kinase (MuSK) Myasthenia Gravis. Current neurology and neuroscience reports. 2016;16:61. 3. Koneczny I, Cossins J and Vincent A. The role of muscle-specific tyrosine kinase (MuSK) and mystery of MuSK myasthenia gravis. J Anat. 2014;224:29-35. 4. Dalmau J and Rosenfeld MR. Paraneoplastic syndromes of the CNS. The Lancet Neurology. 2008;7:327-40. 5. Evoli A and Lancaster E. Paraneoplastic disorders in thymoma patients. J Thorac Oncol. 2014;9:S143-7.

Things you need to know about the way anti-epileptic drugs affect each other, all in one podcast. Take a few minutes here to familiarize yourself with these common and critical complications of seizure management. 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. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. The content in this episode was vetted and approved by Danielle Becker. REFERENCES 1. Perucca E. Clinically relevant drug interactions with antiepileptic drugs. Br J Clin Pharmacol. 2006;61:246-255 2. Pennell PB, Newport DJ, Stowe ZN, Helmers SL, Montgomery JQ, Henry TR. The impact of pregnancy and childbirth on the metabolism of lamotrigine. Neurology. 2004;62:292-295 3. Petrenaite V, Sabers A, Hansen-Schwartz J. Individual changes in lamotrigine plasma concentrations during pregnancy. Epilepsy Res. 2005;65:185-188 4. Pennell PB, Peng L, Newport DJ, Ritchie JC, Koganti A, Holley DK, et al. Lamotrigine in pregnancy: Clearance, therapeutic drug monitoring, and seizure frequency. Neurology. 2008;70:2130-2136