Status epilepticus (SE) is a neurological emergency associated with a high mortality rate. Collaborative efforts have been made to establish standardized definitions, classifications, and treatment protocols to improve management and reduce mortality. In 2015, the International League Against Epilepsy (ILAE) developed a new definition and classification system for SE, taking into account the pathophysiology of SE and setting time points for treatment decision-making, while considering the variability in seizure semiology. Timely identification of the underlying cause of SE would facilitate more targeted treatment, as almost half of all SE cases require specific therapy for the underlying cause in addition to providing symptomatic treatment. A stepwise algorithm for seizure management is proposed, with the initial stage involving the administration of benzodiazepines (BZD), followed by the use of non-sedating anti-seizure medications (ASM) as the second line of treatment. The decision to resort to therapeutic coma is made on a case-by-case basis, as most invasive treatments may not always be the best approach. This comprehensive review provides an overview of SE and its definition, pathophysiology, diagnostic challenges, and recent treatment advances.
OBJECTIVES:To evaluate the diagnostic performance of iodine density map (IDM) using dual-energy CT (DECT) in differentiating colorectal cancer from benign colorectal wall thickening. MATERIAL AND METHODS:This IRB-approved dual-center retrospective exploratory study included 71 consecutive patients with colorectal wall thickening due to tumoral or non-tumoral origin, confirmed by colonoscopy and assessed with DECT. Thirty-eight had pathology-proven colorectal adenocarcinoma, and 33 had non-neoplastic thickening (inflammation, physiologic collapse, or post-radiotherapy change). Iodine density values were measured from regions of interest on three consecutive CT slices on portal venous phase, normalized to aortic iodine concentration. Diagnostic performance was determined by ROC analysis, and inter-reader agreement was evaluated with intraclass correlation coefficients (ICC) and limits of agreement (LOA). RESULTS:Mean IDM value was significantly higher in tumors than in benign thickening (2.31 ± 0.42 vs 1.43 ± 0.24 mg/mL; p < 0.001). Mean normalized iodine density map (NIDM) value was likewise elevated in tumors (0.46 ± 0.10 vs 0.31 ± 0.07; p < 0.001). ROC analysis demonstrated excellent performance for both IDM (AUC 0.98; optimal cutoff 1.72 mg/mL; sensitivity 92.1%, specificity 90.9%, NPV 90.9%) and NIDM (AUC 0.88; cutoff 0.35; sensitivity 92.1%, specificity 69.7%, NPV 88.7%). There was no significant difference between the inflammatory and collapsed-wall subgroups. Inter-reader agreement was excellent (ICC: 0.93 for IDM; 0.92 for NIDM). CONCLUSION:IDM and NIDM on DECT provide robust, reproducible markers that differentiate colorectal carcinoma from benign wall thickening with high diagnostic accuracy. These quantitative parameters may improve diagnostic confidence and reduce unnecessary colonoscopies, supporting their integration into colorectal cancer evaluation.
Importance:Impairment of working memory (WM), which relies on distributed cortical and subcortical structures, including cerebello-striatal pathways, is a core contributor to functional decline in patients with mild cognitive impairment (MCI) and dementia. Because the striatum is affected early in dementia, whereas the cerebellum remains relatively preserved, the cerebellum may offer support for maintaining striatal function in neurodegenerative diseases. Objective:To evaluate whether sequential cerebellar transcranial magnetic stimulation (TMS) and striatal transcranial temporal interference stimulation (tTIS) enhances WM in patients with MCI, especially those with early striatal degeneration, like MCI with Lewy bodies (MCI-LB). Design, Setting, and Participants:This randomized, quadruple-blind, placebo-controlled, crossover trial was conducted from August 2023 to October 2024 at 1 site in Switzerland and 1 in Czech Republic. Participants included individuals with MCI-LB or amnestic MCI (aMCI) and age-matched healthy controls (HCs). Intervention:Three pseudorandomized single stimulation sessions: (1) cerebellar TMS followed by striatal tTIS, (2) control TMS followed by striatal tTIS, and (3) an active control combining control TMS with control striatal tTIS. Main Outcomes and Measures:The primary outcomes were changes in accuracy and correct answer reaction times in a visual WM task with varying memory loads and distractors. Modulators included resting-state functional connectivity and gray-matter volume in WM-related regions. Linear mixed-effects models were used to examine the main effects of stimulation condition on accuracy and reaction times. Results:Forty-one patients with MCI, including 21 with MCI-LB (16 female [76%]; mean [SD] age, 71.05 [6.84] years) and 20 with aMCI (11 female [55%]; mean [SD] age, 72.30 [7.50] years), and 20 HCs (10 female [50%]; mean [SD] age, 69.5 [4.42] years) were analyzed. In patients with MCI-LB, cerebellar TMS plus striatal tTIS increased accuracy in distractor trials compared with the active control (control TMS plus control tTIS, P < .001; d = -0.77) and striatal tTIS alone (control TMS plus striatal tTIS, P = .004; d = -0.60). Greater accuracy gains were associated with lower putaminal connectivity (r = -0.66; P = .03). In patients with aMCI, cerebellar volumes showed associations with task performance in both distractor trials (cerebellar TMS plus striatal tTIS, R2 = 0.27; P = .02) and high-load trials (control TMS plus striatal tTIS, R2 = 0.24; P = .03), and larger volumes were associated with faster responses; however, significant behavioral differences between active and control stimulation conditions were not observed. No serious adverse events occurred. Conclusions and Relevance:Synergistic dual-target cerebellar TMS and striatal tTIS improved WM in MCI-LB, particularly in patients with lower striatal connectivity, suggesting dual-targeted neuromodulation as a potential therapeutic avenue in neurodegenerative disorders. Trial Registration:ClinicalTrials.gov Identifier: NCT07090681.
BackgroundMinor hallucinations (MH) affect 30-60% of patients with Parkinson's disease (PD), and are considered precursors to structured visual hallucinations and cognitive decline. While the link between structured visual hallucinations and dementia is well established, the neuropsychological correlates of MH in PD remain unclear; most studies finding no significant cognitive differences between patients with MH and those without any hallucinations.ObjectivesPresence hallucinations (PH) being among the most prevalent MH in PD, we used a robotic procedure delivering somatomotor conflicts inducing PH experimentally to investigate whether sensitivity to such robot-induced PH aids in detecting cognitive differences between patients with MH and without hallucinations.Methods31 PD patients with MH (PD-MH) and 37 without hallucinations (PD-nH) underwent neuropsychological assessment and the robotic procedure inducing PH. The sensitivity to report robot-induced PH was analyzed in relation to cognitive performance in neuropsychological tests.ResultsPD-MH patients reported more robot-induced PH than PD-nH patients, supporting previous findings. While both groups showed comparable performance in neuropsychological testing, we found a significant association between increased sensitivity to the PH-induction and poorer performance in frontal subcortical cognitive functions, in PD-MH patients, but not in PD-nH patients.ConclusionsThese findings demonstrate that sensitivity to robot-induced PH reveals a previously undetected link between MH and frontal subcortical cognitive deficits in PD, pointing to shared underlying mechanisms between executive dysfunction and somatomotor processes involved in MH. This approach offers a novel and clinically valuable means of identifying early cognitive vulnerability that assessments relying only on standard testing may overlook.
BACKGROUND:Longer total stent length (TSL) increases the risk of target lesion failure (TLF) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention with second-generation drug-eluting stents (DES). We aimed to assess the long-term impact of TSL on patient- and stent-related outcomes in STEMI patients treated with different newer-generation DES designs. METHODS:We performed a post hoc subgroup analysis of the BIOSTEMI Extended Survival randomized trial (NCT05484310). Patients undergoing primary percutaneous coronary intervention for STEMI were randomized to ultrathin-strut biodegradable-polymer sirolimus-eluting stents (BP-SES) or thin-strut durable-polymer everolimus-eluting stents (DP-EES) and categorized according to TSL implanted at the culprit site (≤40 vs >40 mm). The device-oriented composite endpoint (TLF) was the composite of cardiac death, target-vessel myocardial reinfarction, or clinically indicated target lesion revascularization, and the patient-oriented composite endpoint was the composite of all-cause death, any myocardial reinfarction, any revascularization, or any stroke, at 5 years. RESULTS:A total of 1,686 STEMI patients were included (mean age, 62.4 years; female, 23%; mean TSL, 33.8 mm), of whom 423 (25%) were treated with TSL >40 mm. At 5 years, TSL >40 mm was associated with a significantly higher risk of patient-oriented composite endpoint compared with TSL ≤40 mm (31.7% vs 27.4%; hazard ratio [HR], 1.30; 95% confidence interval [CI], 1.03-1.64; P = .029), whereas no difference was observed in TLF. However, there was a significant interaction between DES type and TSL for TLF at 5 years. Among patients with TSL >40 mm, BP-SES were associated with a lower risk of TLF compared with DP-EES (7.3% vs 17.1%; HR, 0.39; 95% CI, 0.21-0.74; P = .004; P for interaction = .032), a difference primarily driven by a lower rate of target vessel myocardial reinfarction. No significant differences between BP-SES and DP-EES were observed in patients with TSL ≤40 mm. After adjustment for multivessel treatment, increasing TSL with DP-EES, but not BP-SES, was independently associated with a higher risk of TLF (adjusted HR per 5-mm increase, 1.07; 95% CI, 1.02-1.11; P = .003). CONCLUSION:In STEMI patients treated with contemporary DES, TSL >40 mm was associated with an increased risk of patient-oriented, but not device-related, adverse outcomes at 5 years. Among patients requiring TSL >40 mm, ultrathin-strut BP-SES significantly reduced the risk of TLF compared with DP-EES, whereas no between-DES differences were observed in patients treated with TSL ≤40 mm. TRIAL REGISTRATION:The BIOSTEMI ES trial is registered at ClinicalTrials.gov (NCT05484310).
