1/WE'RE BACK!
A 52 yo architect presents with a year of difficulty with memory & planning.

At work, she can't adapt to the new software.

Family notes she “forgot” steps in planning their annual vacations (“she didn’t book the hotel!”)

She's increasingly irritated & withdrawn. 2/
At work this had led to significant trouble and her manager has asked her to cut back on hours. She became increasingly anxious at work and irritated.

Her primary care doctor ordered an MRI which was reported as normal, particularly noting normal hippocampus volume.

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I once heard that a fever in the ICU was a "fever of too many origins."

Same can be said altered mental status/encephalopathy!

We put together a comprehensive approach to these challenging patients for #SeminarsinNeurology

A thread with our approach!
pubmed.ncbi.nlm.nih.gov/39137901/ 2/
Start with 'is the AMS appropriate for the degree of critical illness?'

Often it is.

But do some digging, did the AMS precede the illness? ...Is it more than what you would expect?

Start with this flow chart⬇️

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A 34 yo M presents with worsening confusion and seizures. He is febrile.

He is intubated and transferred to the NeuroICU.

A #continuumcase about a cause that’s probably low (not) on your DDx. 2/
I’m not even going to ask if you want an LP next, because “Fever, Status, AMS” = I wanted that LP way before this MRI.

You get one and the protein is 80, TNC #155, and glucose 80 (serum 147). Cultures and HSV PCR are pending.

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A 75 yo M is brought in by his wife bc he is forgetful & “continues to drop things.”

She notes he's increasingly tearful, forgetful, and has an odd movement in his right hand.

MRI, EEG, LP were all normal.

In the room he keeps doing this with his face:
A #ContinuumCase 2/
What do you worry about most?

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25-yo M p/w status epilepticus.

He has been paranoid and confused in the previous weeks.

MRI 👇. A large abdominal mass was identified on imaging.

You know what this is, but do you know why we treat it the way we do?

A #ContinuumCase on immunomodulators 2/
ok ok, everyone gets to vote on what's going on before we dive in on how we are going to treat it and why.

so what do you think?

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A 30 yo woman p/w 2 days of worsening paraparesis, left arm paresthesias and urinary retention. No change in vision.

Exam: hyperreflexic in the legs bilaterally+ sensory level at T10.

MRI C/T Spine + MRI Brain. And you find this … what to do for this #continuumcase? 2/
Just looking at the scan, history, and her demographic, what do you think?

1/ A 63 yo W presented after a fall down stairs. She’s initially confused and then collapses.

Her left pupil is dilated and non-reactive! CT scan👇

Our NSGY friendsevacuate the blood 🙏, and she much improved … initially.

But then she has fluctuating aphasic.

What now? 2/
Subdurals are an increasing problem given the aging population and anticoagulation use.

Primary evacuation is recommend when thickness > 10mm or shift >5mm regardless of GCS

+for those patients who are significantly symptomatic regardless of size (our patient meets both)

1/ A 20 yo woman comes in because she has recurrent headaches. She describes visual aura, photo-/phonophobia & pain that improves with rest. She also describes a sharp, stabbing, lancinating pain from the back of her head during the episodes.

A #ContinuumCase 2/
What is this?

(PS ChatGPT FTW with "what does an aura look like?" !!)

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🥳Big News! This is the 1⃣0⃣0⃣th #CONTINUUMCASE!!

To celebrate? A must know dz, bc w/ this disease:

Time is Spine!

A 39 yo woman with Sjogren’s syndrome comes to the ED with sudden neck pain. Then arm weakness. Then leg weakness. All within 24 hours.

Now she can’t urinate 2/
On your exam, mental status=intact. But she has terrible vision in the right eye, which she reports is from a sjogrens attack.
She has 3/5 arm strength, 2/5 leg strength.
As shown above 🔼 she has a longitudinally extensive lesion w/ contrast at C2 and C3.

Is this Sjogrens?

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A 25-year-old woman presented with a new-onset seizure.

She has no past medical history.

An MRI demonstrates the following and a resection confirms a glioblastoma.

A #ContinuumCase about tumor genetics. 2/
Honestly, I find this subject to be confusing.

But there is at least one molecular signature of gliomas that is worth knowing:

Is the tumor is Isocitrate Dehydrogenase (IDH)-wildtype or IDH mutant?

Which, generally, has a more favorable prognosis?

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📟Onc floor pages you STAT:

A 58 yo woman with breast cancer on active chemo presented with shortness of breath.

She was just found to have (A).

Unfortunately, a head CT reveals (B).

They want to know – can she be a/c’ed? A #ContinuumCase 2/
Thoughts?

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A 35 yo M has lower limb weakness & painful hand & foot paresthesias.
EMG suggested axonal neuropathy and a presumed diagnosis of GBS was made.
After PLEX he was not better, instead he was becoming confused & ataxic.

How might a Thanksgiving Turkey solve this #ContinuumCase? 2/
Note: PLEX does not work immediately. In fact, many pts fail to have a response to immunotherapy during their hospitalization. Many continue to progress DESPITE treatment.

This does not mean that the treatment isn’t working. More is not better!

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In 1965, 17-year-old Randy set the world record for sleep deprivation by staying awake 264.4 hours (about 11 days) for a science fair experiment.

11 days!!!

But what about the patient that desperately wants to sleep… and can’t?

A #ContinuumCase about 20 million US adults. 2/
Insomnia is the most common sleep disorder.

Almost everyone has experienced insomnia at some point, but 6% of the US population has chronic insomnia….

That’s the 20 million people.

1/A 60 year old man is brought to neurology clinic after injuring his spouse in the middle of the night

“I feel so bad, I was dreaming that a tiger was chasing me!”

This has happened multiple times.
A polysomnogram demonstrates the following.

What is going on? A #ContinuumCase 2/
I know you probably aren't an expert polysomnographer (I'm certainly not!) but what do you think is going on?

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A 73 yo woman is admitted for TIA-evaluation. While in the hospital you find her pacing the floor at night.

“I just have to move my legs at night!”

You see the blood work done by her PCP and her iron levels are… normal.

What’s going on?
A #ContinuumCase @ContinuumAAN 2/
What’s your guess about the cause of her "need to move" at night?

1/ Alright #neuroX (?!?!)

A 78 yo man is hospitalized with sepsis, he undergoes a long hospitalization complicated by ileus and AKI requiring HD (now resolved).

He has been hospitalized 62 days.

The ICU team calls you for ?refractory delirium?

A #ContinuumCase (image mine) 2/
On exam you find a man that is frail and inattentive. He is slow with tracking you around the room.

He does not participate in serial 7s or saying the days of the week backwards.

He’ll follow simple commands and is able to name simple objects.

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A 72 yo man w/ ESRD presented w/ worsening lethargy and poor arousal. He had missed 2 sessions of dialysis.

While in the ED he had some “twitching” and was hooked up to cEEG.

At first, the EEG looked like panel A.

But later, panel B.

A #continnumcase. 2/
What’s going on in panel A?

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#ContinuumCase for the New Academic Year!!!

Step 1⃣: Get an @AANmember resident membership and get @ContinuumAAN🆓!!!

Step 2⃣: play along
A 27 yo man is brought in obtunded.

Nothing is known about his PMH.

A head CT is completed demonstrating sulcal effacement and edema. 2/
Acute obtundation is a stressful situation.
🥴Toxic metabolic causes are more likely than primary neurologic issues. Think Narcan first.

But if that doesn’t work...

In any case with acute or unexplained AMS, I always ask myself—*is this a basilar thrombus*?

CTA exonerated.

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A 32 yo woman presents with headache and somnolence.

She is febrile to 102.6F.

Exam reveals neck stiffness and this rash…which, when your attending arrives, is absent #hatethat!

A #continuumcase @ContinuumAAN @LyellJ 2/
Rashes can be a sign of many neurocutaneous disorders & infectious etiologies.

High fever + neck stiffness + a rash=🔼 concern for neisseria meningococcal meningitis

However, the rash in meningococcal meningitis is often caused by DIC, looks more like this & doesn't vanish

1/ #ContinuumCase!!

A 50 yo man presented to the ED with acute onset aphasia. He is not able to report a history, but BP Is 215/95.

Non-contrast HCT reveals this bleed…
What do you want to see next? 2/
What do you most want next?

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🚨Code stroke to the Med-Surg floor!

53 yo M with hep C & IVDU admitted yesterday for fever & chills.

BCx=GPCs in clusters😨. An ECHO is planned.

He develops witnessed-onset R sided weakness & aphasia. Head CT👇

Do you push tPA?

A #continuumcase 2/
LSW <2 hours ago. Head CT with no ICH.

Do you push tPA?