Background: Orthostatic tremor (OT) is characterized by high-frequency leg tremor when standing still, resulting in a sense of imbalance, with limited treatment options. Ventral intermediate (Vim) nucleus thalamic deep brain stimulation (DBS) has been reported as beneficial in a few cases. Objective: To report clinical outcomes, lead locations, and stimulation parameters in 2 patients with severe medication-refractory OT treated with Vim DBS. Methods: The patients underwent surface electromyography (EMG) to confirm the OT diagnosis. Outcomes were measured as change in tolerated standing time at the last follow-up. Lead locations were quantified using postoperative MRI. Results: Vim DBS was well tolerated and resulted in improvement in standing time (patient 1: 50 s at baseline to 15 min 16 months after surgery; patient 2: 34 s at baseline to 4.2 min 7 months after surgery). Postoperative surface EMG for patient 1 demonstrated a delayed onset of tremor, lower-amplitude tremor, and periods of quiescence, but an unchanged tremor frequency. Conclusion: These cases provide further support for Vim DBS to improve standing time in severe medication-refractory OT. The location of the effective thalamic target for OT does not differ from the effective target for essential tremor.

Background: Medically refractory dystonia affects children and young adults, and deep brain stimulation (DBS) can allow some patients to regain functional independence. Women with dystonia treated with DBS may wish to conceive a child, but there is limited published information on pregnancy and DBS. Objective: To describe a series of dystonia patients treated with DBS who later became pregnant and provide guidelines for women treated with DBS considering conception. Methods: We reviewed all dystonia DBS cases implanted at the University of California, San Francisco, and University of Alabama at Birmingham from 1998 to 2015 and identified patients who became pregnant. Patient records were reviewed and structured interviews were conducted. Results: Six dystonia patients were identified [1 currently pregnant and 7 live births (including 1 twin pair)]. Patients (n = 5) with pre- and postoperativeBFMDRS (Burke-Fahn-Marsden Dystonia Rating Scale) scores improved by 65.9% after DBS. All pregnancies and deliveries were uncomplicated (the delivery mode was not influenced by the presence of DBS), except for 1 child, who was born premature at 35 weeks' gestation. Stimulation remained on (n = 3) or off (n = 4) during deliveries. DBS neurostimulators did not hinder breastfeeding. Conclusions: In this small sample, pregnancy, delivery, and breastfeeding were safe in dystonia patients treated with DBS. The presence of DBS should not be a contraindication to pregnancy.

Background Deep Brain Stimulation (DBS) for Parkinson disease (PD) may be underutilized because of limited access to care (most DBS surgeries are performed at specialized centers) or over-referral of poor candidates, leading to inequitable utilization of limited evaluative resources. There is a pressing need for a widely employable screening algorithm to aid in the evaluation of PD candidates for DBS. Objective To compare the validity and efficacy of two published screening algorithms, the Florida Surgical Questionnaire for PD and Stimulus, to predict candidacy for DBS. Methods We reviewed the clinical data at our DBS center for 147 consecutive PD DBS referrals between 9/1/2007 and 12/31/2011. Florida Surgical Questionnaire and Stimulus scores were applied retrospectively through a chart review of the Movement Disorder neurologist's initial clinical evaluation. The validity and accuracy of these two algorithms in predicting candidacy for DBS was compared to the decision to offer DBS surgery by our multidisciplinary DBS team. Results Of the 130 consecutive PD referrals who presented for initial evaluation, 50 were offered DBS after a standardized multidisciplinary evaluation. The Stimulus scale was a superior screening tool for predicting PD DBS candidacy in these referrals [Area under the Receiver operating curve = 0.8088] compared to the Florida Surgical Questionnaire for PD [Area under the Receiver operating curve = 0.6285]. Conclusion In this single center study, Stimulus was a more appropriate screening measure than the Florida Surgical Questionnaire for PD to assess DBS candidacy for PD.

Simulation training is a beneficial part of medical education for APPs and should be considered in addition to traditional didactics and clinical training. Further research is needed to determine whether simulation education of APPs results in improved treatment times and outcomes of acute stroke patients.

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Introduction: Neurology led Stroke Teams are becoming imperative in recent care models of acute stroke management. Advanced Practice Providers (APP) are important members of these stroke teams. Code Stroke simulations allow (APP) to gain valuable experience in the evaluation and treatment of a potential stroke patient without compromising patient care. We hypothesized that simulation training would increase advanced practice provider confidence, comfort level and preparedness in leading a Code Stroke similar to neurology residents. Methods: Nine advanced practice providers and nine neurology residents each took turns leading a Code Stroke simulation to determine need for intravenous thrombolysis, thrombectomy and blood pressure management on three cases with standardized patients. Emergency medicine physicians and neurologists were preceptors and gave feedback. APPs and residents completed a survey before and after the simulation. Generalized mixed modeling assuming a binomial distribution was used to evaluate change. Results: On a 5-point Likert scale (1 - Strongly disagree and 5 - Strongly agree), confidence in leading a Code Stroke significantly increased from (2.8 to 4.5, p<0.01) comfort level in rapidly assessing a stroke patient for thrombolytics increased (3.0 vs. 4.3 p<0.001), making the decision to give thrombolytics increased (2.7 vs. 4.3, p<0.01) and assessing a patient for embolectomy increased (2.6 vs. 4.3, p<0.01); these results held for both APP and residents. Conclusion: Simulation training is a beneficial part of medical education for advanced practice providers and should be considered in addition to traditional didactics and clinical training.