ObjectiveWe tested the hypothesis that epileptic, but not non-epileptic, seizures would produce an improvement in comorbid depression and anxiety symptoms in the peri-ictal period, much like the antidepressant effects of electroconvulsive therapy.MethodsWe examined depression and anxiety symptoms in patients admitted to an inpatient unit for continuous video electroencephalography as part of routine clinical care. Patients completed three questionnaires that included the Beck Depression Inventory-II (BDI), Montgomery Asberg Depression Rating Scale (MADRS), and Beck Anxiety Inventory (BAI) after admission, in the 24 h following a seizure, then again 2 weeks after the last seizure.ResultsIn patients with epilepsy, depression and anxiety scores improved in the 24 hrs following a seizure (change in BDI = 24%; change in MADRS = 19%; change in BAI = 21%) but returned toward baseline after 2 weeks. In patients with non-epileptic seizures, depression and anxiety scores also improved in the 24 hrs following a psychogenic non-epileptic seizure (change in BDI = 17%, change in MADRS = 27%, change in BAI = 36%). There was a greater improvement in depression and anxiety scores in patients with focal-onset epilepsy (BDI = 30%, MADRS = 22%, BAI = 30%) compared to generalized seizure onset (BDI = 6%, MADRS = 12%, BAI = 8%).ConclusionWe conclude that single seizures can result in transient improvements in mood. Because seizures need not be generalized or epileptic to exert this effect, the underlying mechanisms are uncertain.
Introduction: Hyperlipidemia is a modifiable risk factor for stroke, with the magnitude of LDL-C reduction correlating to risk of recurrent ischemic stroke. A high-intensity statin is considered standard of care in addition to dietary modification. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are used if the LDL-C target is not achieved despite maximally tolerated statins with ezetimibe. We investigated the role for PCSK9 inhibitors in our ischemic stroke population. Methods: An IRB approved retrospective review of patients admitted for acute ischemic stroke between 2019 – 2020 was performed. We estimated the probability of benefit from PCSK9 treatment with the following criteria: LDL > 190 regardless of treatment, LDL 161-190 on any dose statin therapy, and LDL 131-160 on high intensity statin therapy. Results: 774 patients with ischemic stroke were admitted during this time frame. Mean age 62.8 +/- 13.2 with 57% male (52% Black, 42% White). 584 (75%) of these patients had LDL above goal. One patient was on PCSK9 therapy on admission. Although the majority of our patients had uncontrolled cholesterol, only one additional patient would meet the strict prescription criteria for PCSK9 therapy of being adherent to maximal tolerated statin dose and ezetimibe with LDL above goal. Other potential patients with estimated benefit include LDL >190 (20 patients), LDL 161-190 (16 patients), LDL 131-160 (13 patients). In total this amounts to 6.7% of stroke patients who we would expect to need PCSK9 inhibitors in the future. Conclusion: Using conservative projections, we estimate that about 1 in 14 patients with ischemic stroke could benefit from PCSK9 therapy. Achieving LDL targets more consistently is a promising approach to decreasing the recurrent stroke rate. Further prospective data evaluating outcomes after initiating PCSK9 inhibitor treatment are needed to validate these findings.
Thromboses of the cerebral arterial and venous systems are a common manifestation of antiphospholipid syndrome (APS) often leading to ischemic and hemorrhagic stroke. APS increases stroke risk via many mechanisms, including hypercoagulability and inflammation. These mechanisms, among others, must be considered by physicians when evaluating and treating such patients to achieve optimal short- and long-term outcomes. In this chapter, we will discuss the epidemiology of APS as it relates to neurological disease focusing on stroke, APS stroke mechanisms, suggested clinical evaluations, acute treatment strategies, and long-term secondary stroke prevention strategies. Current consensus statements and the most recent literature will be summarized.
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