Inpatient video-EEG epilepsy monitoring aims to provide a safe environment for antiseizure medication (ASM) tapering to precipitate seizures, which is often required for diagnosis and treatment. However, there is no standardized taper protocol across institutions, which may contribute to increased morbidity through longer hospitalizations if the taper is too mild and bilateral tonic-clonic seizures (BTCSs) if too aggressive. This study investigates how ASM taper influences length of stay (LOS) and patient outcomes in the epilepsy monitoring unit (EMU), aiming to develop guidelines for medication taper strategies to maximize diagnostic yield while minimizing patient risk. We used natural language processing to extract data from electronic medical records of 639 patients admitted to the University of Pennsylvania EMU between 2017 and 2023. We estimated ASM load, the total normalized sum of all ASM serum concentrations based on dose-dependent pharmacokinetic models, throughout each hospitalization. We applied LASSO (Least Absolute Shrinkage and Selection Operator) regression and mixed-effects models to identify predictors of LOS and BTCS risk as a function of taper speed and percentage of baseline ASM load in patients with (hBTCS) and without (nBTCS) a history of BTCS. Taper speed did not correlate with BTCS risk, although absolute ASM load did. Median ASM loads at seizure occurrence were 51% of baseline in the hBTCS group, 41% in the nBTCS group, and 39% in the unclear group. BTCS occurred at higher ASM loads in patients with hBTCS vs nBTCS. Median ASM loads at first EMU seizure were 33% for both hBTCS and nBTCS groups, while the unclear group had first seizures at lower loads (25% of baseline). Time to first seizure and number of baseline ASMs were positively correlated with longer hospital stays, suggesting that sequential medication taper delayed seizures and prolonged LOS without altering BTCS risk. Patient history and ASM load are critical factors in predicting BTCS. Rapid taper to approximately 50% baseline ASM load may more efficiently produce seizures without increased BTCS risk in patients without BTCS history. Individualized taper protocols remain advised, particularly for severe epilepsies. This study provides a foundation for quantitative, evidence-based guidelines to optimize ASM reduction strategies for safely precipitating seizures in EMUs.

To support general neurologists, advanced practice providers, and general practitioners in the diagnosis and treatment of postural tachycardia syndrome (POTS) and related dysautonomias. This review and approach are based on the authors' clinical experience, nonsystematic literature review, and expert opinion, with experts drawn from the American Autonomic Society Education Committee. POTS is a common condition seen in general practice. The diagnosis can be easily made in a nonspecialist setting when patients meet the syndromic criteria for POTS: (1) chronic orthostatic intolerance (bothersome symptoms brought on by upright posture, and relieved by lying down), (2) excessive orthostatic tachycardia (heart rate augmentation with standing greater than 30 beats per minute in adults), (3) absence of orthostatic hypotension, and (4) reasonable exclusion of other causes (e.g., dehydration, anemia, hyperthyroidism). There are many causes, but the unifying perturbations are low effective circulating volume with decreased cerebral blood flow and a hypersympathetic state. Education and nonpharmacologic therapies such as salt, water, and exercise are first-line treatments. Several safe and effective medication options are also available, such as propranolol and midodrine. Several comorbidities are common, such as migraine and neurocardiogenic syncope, and should be screened for and treated rather than attributed out-of-hand to POTS. POTS and related conditions are common. Initial diagnostic and treatment steps can be undertaken in a general practice setting. Referral to specialists is appropriate for refractory cases or when the diagnosis is uncertain.

Intravenous ketamine is increasingly used for refractory and super-refractory status epilepticus (RSE/SRSE), yet its efficacy and optimal use remain uncertain. We therefore aimed to synthesize the available evidence to quantify the effectiveness of ketamine in achieving seizure cessation and to explore differences in treatment characteristics between patients who respond and those who do not. We conducted a systematic review and meta-analysis to estimate the pooled seizure cessation rate associated with intravenous ketamine. Secondary analyses compared ketamine initiation timing, dosing, and infusion duration between patients who achieved seizure cessation (responders) and those who did not (nonresponders). Fourteen studies comprising 388 adult patients (249 responders, 139 nonresponders) were included. The pooled seizure cessation rate with ketamine was 64% (95% CI 49%-76%) with moderate heterogeneity (I 2 = 54.1%). Sensitivity analysis showed no single study substantially influenced results, supporting robustness. Responders received ketamine earlier (3.2 ± 2.6 days) than non-responders (4.3 ± 2.6 days), mean difference of -0.90 days (95% CI: -1.31 to -0.49; p < 0.0001). The mean maintenance dose was 2.5 ± 1.4 mg/kg/hr (responders: 2.5 ± 1.3; nonresponders: 2.6 ± 1.4), with no significant difference between groups (mean difference -0.14 mg/kg/hr; 95% CI -0.45 to 0.18; p = 0.39). Infusion duration averaged 5.0 ± 4.2 days in both groups, with no significant difference (mean difference -0.07 days; 95% CI -1.02 to 0.88; p = 0.88). Ketamine discontinuation due to adverse events was rare (0.7%, 3/55 patients). Intravenous ketamine demonstrates consistent effectiveness and safety as an adjunctive therapy in RSE/SRSE. However, the timing of initiation cannot be reliably linked to improved clinical outcomes given current methodological limitations and heterogeneity across studies. Future prospective research using standardized definitions and rigorous temporal data collection is needed to clarify whether the timing of ketamine initiation independently influences therapeutic success and to define its optimal integration within established status epilepticus (SE) treatment algorithms. The systematic review was registered (June 7, 2024) with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42024549523).

CT angiography of the head and neck (CTAHN) is commonly obtained in the emergency department (ED) for patients with acute neurologic symptoms to guide interventions. There are limited data on which clinical characteristics predict these changes. The primary objective of this study was to assess the yield of CTAHN across common neurologic ED presentations and identify patient and clinical factors associated with CTAHN findings that result in acute management change. We performed a retrospective cohort study of 1,445 ED patients at an academic Level 1 trauma center who underwent CTAHN in 2023 for 5 common neurologic presentations: stroke code, headache, dizziness, altered mental status, and vision changes. Multivariable logistic regression models with LASSO variable selection were used to identify predictors of acute management change. Odds ratios (OR), 95% CIs, and p values were reported for each independent predictor. Overall, 216 of 1,445 CTA head and neck sudies (CTAHNs; 14.9%) resulted in acute management change. The highest yield of CTAHN acute management change was for stroke codes (21.2%) and vision changes (14.7%), and the lowest for dizziness (4.0%). For stroke codes, independent predictors included abnormal CT head (OR 2.84, p = 0.0001), focal neurologic deficit (OR 2.2, p = 0.0119), new vs recurring symptoms (OR 2.39, p = 0.0272), maximal symptom severity at onset (OR 3.95, p = 0.0011), and tobacco use (OR 2.02, p = 0.0016). National Institutes of Health Stroke Scale (NIHSS) scores of 10-14 had the highest likelihood of CTAHN acute management change. Previous neurologic disorder was protective (OR 0.66, p = 0.0317). For headache, abnormal CT head (OR 4.98, p = 0.0303) and thunderclap presentation (OR 5.31, p = 0.0276) were associated with CTAHN acute management change. Only univariate trends could be identified for dizziness, altered mental status, and vision changes. CTAHN was most useful in those presenting with vision loss or diplopia, but not cases of blurry vision or positive visual phenomena. Abnormalities on the preceding CT head increased the yield for altered mental status, while CTAHNs were low yield for isolated dizziness. These results highlight specific, obtainable clinical predictors that can guide judicious use of CTAHN in the ED. Recognizing these predictors can inform emergency physicians' and neurologists' clinical judgment, optimize imaging utilization, improve resource allocation, and reduce patient burden.

[This corrects the article DOI: 10.1212/CPJ.0000000000200567.].

Numerous observational studies are available to asymptomatic individuals at risk to carry or known carriers of pathogenic variations associated with amyotrophic lateral sclerosis and frontotemporal degeneration (ALS-FTD) spectrum disorders. Little is known about such individuals' motivations for participation or the impact on their emotional well-being. Asymptomatic at-risk adults, with or without genetic status known, were recruited through social media advocacy groups and by National Society of Genetic Counselors ALS-FTD special interest group members. Interviews were conducted through secure videoconferencing. Two coders independently analyzed interview transcripts, followed by thematic content analysis. Twelve participants (9 status-aware and 3 status-unaware) were interviewed, representing experience with 11 observational studies. Some motivations for participation aligned with previous literature, including altruism, health focus, and intellectual interest. Motivations unique to this population stemmed from the hereditary nature of the disease, including fear of future disease onset and the desire to establish a relationship with a specialized clinical care team, reflecting individual, familial, and societal factors. Benefits of participation included meeting these motivational goals, social connection and support, psychological well-being, and practical benefits. Challenges to participation fell into research-related (e.g., struggles with the observational nature of research), disease-related (e.g., anxiety about disease risk), and logistical (e.g., travel and study procedures) categories. Compared with status-unaware participants, status-aware participants more frequently cited individual motivators for research participation and encountered more research-related challenges when their participation did not align with their anticipated personal health benefits. Interviewees found relationships with providers through research to be rewarding but noted confusion between research and clinical care as a significant challenge. Participation in observational research helps address unmet emotional and medical needs for asymptomatic individuals who are at risk of ALS-FTD spectrum disorders. However, some of these needs are beyond the scope of research, highlighting the need for new models of clinical care for at-risk individuals.

With more women entering the medical workforce, caregiving challenges and family-work conflicts are of growing importance to today's neurologists. The aim of this study was to assess the impact of caregiver (CG) status on academic achievements in neurology, analyze the division of labor and time devoted to domestic responsibilities, and measure family-work conflict in US academic neurology faculty. A total of 19 US neurology departments completed a survey on baseline demographics, academic achievements, CG status, division of domestic time and labor, and responses on a FWC scale. Variables were assessed using independent samples t tests (or Mann-Whitney U for non-normally distributed data) and X2 analyses as appropriate, with CGs vs noncaregivers (N-CGs) serving as the independent groups. Women were twice as likely as men to categorize themselves as caregivers (p = 0.005). There were no significant differences in academic achievements between the CG and N-CG groups. However, CG men had a statistically significantly higher number of leadership positions (p = 0.022), number of publications as first or last author (p = 0.020), and number of awards (p = 0.004) when compared with CG women. The percentage of CG women faculty who reported spending more than 22 hours per week on child care was significantly higher than that of CG men (p = 0.003). Caregiver women also reported doing more work at home; taking care of children when they are sick; taking days off work when children are sick; handling more chores related to child care (e.g., managing activities/schedules); and doing laundry, cooking, and cleaning related to child care. Finally, the CG group experienced a higher level of FWC, as evidenced by responses on the FWC scale (p < 0.001). This finding was same for CG women compared with CG men (p = 0.034). Although the caregiving burden did not directly affect academic productivity, it significantly increased FWC in US academic neurology faculty surveyed. Female CG faculty disproportionately shouldered domestic and household responsibilities. Beyond recognizing CG challenges, advocating for a change in paradigm and providing solutions to these pervasive issues could be instrumental in preventing further attrition of professionals from our field, particularly women with caregiving roles.

Burnout is a pervasive occupational hazard for neurologists-undermining their well-being, jeopardizing patient safety and satisfaction, limiting access to care, and inflating health care costs. Well-designed appreciation and recognition practices may help mitigate some of its key drivers. This pilot study evaluates faculty perspectives on appreciation strategies in an academic neurology department. We used the Moffitt Provider Appreciation Assessment (MPAA), which assesses the types of appreciation methods respondents value, regardless of whether those practices are currently implemented in their workplace. A cross-sectional survey was conducted among full-time clinical faculty in the Department of Neurology at NYU Grossman School of Medicine. The survey included demographics, the MPAA, the single-item Mini-Z burnout inventory to assess self-reported burnout levels, and an intent-to-leave question. MPAA responses were analyzed for frequencies, and the association between burnout and intent to leave was examined. Of the 202 faculty members, 77 (38%) participated. The most highly valued appreciation practices were inclusion in decision making (77%), efforts to reduce daily frustrations (75%), and positive feedback from patients and families (71%). Gifts, team celebrations with food, and public affirmations were among the least valued practices. Burnout symptoms were reported by 45% of respondents, and 30% indicated an intent to leave within 2 years. Higher burnout levels were associated with increased intent to leave (p < 0.00001). Because the scores for self-reported burnout and intent to leave reflect current work conditions while MPAA scores capture enduring personal values, MPAA rankings cannot be compared directly with burnout or turnover metrics. Neurology clinical faculty prioritized appreciation methods that directly address clinical work, underscoring the value of implementing tailored recognition practices that may reduce burnout. The methodology used in this pilot study can be adapted for broader application in other settings. After identifying faculty preferences, health care organizations can implement meaningful, transparent, and inclusive appreciation strategies that have the potential to strengthen physician relationships, promote well-being, and support a sustainable workforce.

The aim of this study was to explore practice patterns in managing mild cognitive impairment (MCI). The investigation and management of MCI is considered important because it offers the opportunity to potentially stave off conversion to dementia. However, there are few data on current practices/approaches in this area, especially worldwide; such data can help identify potential disparities and anticipate adoption of new therapies. We performed a worldwide electronic survey of neurology practitioners through the Practice Current section of Neurology® Clinical Practice with clinical and practice-related questions in November 2019-August 2021 and repeated it in May-October 2023 after the FDA's approval of aducanumab and lecanemab but before the approval of donanemab. Clinical questions addressed access to and utilization of diagnostic investigations, pharmacologic and nonpharmacologic management of MCI, and (in 2023) attitudes toward novel anti-amyloid agents. Responses were compared using the Fisher exact test and multivariable logistic regression adjusted for region, regional income, year of survey response, years in practice, and number of cognitive patients seen annually. We received 1,257 responses from 95 countries, including 237 cognitive subspecialists and 464 respondents from low-/middle-income countries. On multivariable analysis, cognitive subspecialists were more likely than other practitioners to investigate MCI with a lumbar puncture (aOR 1.90, 95% CI 1.32-2.73), luorodeoxyglucose-PET (FDG-PET) (aOR 1.45, 95% CI 1.00-2.10) and to offer pharmacotherapy if investigations suggested neurodegeneration (aOR 1.92, 95% CI 1.29-2.85). Regionally, respondents from Europe, Latin America, and Asia were more likely than those from the United States/Canada to order FDG-PET (e.g., Europe: aOR 2.38, 95% CI 1.29-4.39) and amyloid PET (Europe: aOR 3.30, 95% CI 1.85-5.87), controlling for reported access to these tests. Pharmacologic and nonpharmacologic approaches were comparable between cognitive subspecialists and other respondents. Despite concerns about safety (77.1% expressed being somewhat or very concerned), attitudes toward prescribing new anti-amyloid agents were similar among all respondents, reflecting a generally favorable attitude (e.g., 62% would prescribe anti-amyloid therapy if it was available). Our results highlight practice differences among cognitive subspecialists and other practitioners worldwide in the management of MCI. Attitudes toward anti-amyloid therapy indicate cautious optimism, with concerns about side effects but a general interest to prescribe.