Clinical Instructor, Neurology & Neurological Sciences
Fellowship: Stanford University Dept of Neurology (2022) CA
Board Certification: American Board of Psychiatry and Neurology, Neurology (2021)
Residency: Stanford University Dept of Neurology (2021) CA
Internship: Cedars Sinai Medical Center Internal Medicine Residency (2018) CA
Medical Education: University of Pennsylvania Hospital (2017) PA
Transcranial Direct Current Stimulation for Focal Status Epilepticus or Lateralized Periodic Discharges in Four Patients in a Critical Care Setting.
OBJECTIVE: Transcranial direct current stimulation (tDCS) has been advocated for various neurological conditions, including epilepsy. A 1-4 mA cathodal current applied to the scalp over a seizure focus can reduce spikes and seizures. This series of four patients with focal status epilepticus is among the first case series to demonstrate benefit of tDCS in the critical care setting.METHODS: Patients in the intensive care unit were referred for tDCS treatment when focal status or clinically-relevant lateralized periodic discharges did not resolve with conventional anti-seizure medications and anesthetics. Battery-powered direct cathodal current at 2 mA was delivered by an ActivaDose (Caputron) tDCS device via a saline soaked sponge on the scalp over the seizure focus. Anode was on the contralateral forehead or shoulder. Treatment was for 30 minutes, repeated twice in a day, then again 1-4 times more over the next few days.RESULTS: Three females and one male, ages 34-68 were treated. Etiologies of status were PRES in association with immunosuppressants for a liver transplant, perinatal hypoxic-ischemic injury, a prior cardioembolic parietal stroke and CNS lupus. tDCS led to significant reduction of interictal spikes (0.78/s to 0.38/s, p<0.0001) in 3 cases and electrographic seizures (3.83/hr to 0/hr, p<0.001) in two cases. Medication reductions were enabled in all cases subsequent to tDCS. The only side effect of tDCS was transient erythema under the sponge in one case. Two patients died of causes unrelated to tDCS, one was discharged to a nursing home and one became fully responsive as seizures were controlled with tDCS.SIGNIFICANCE: Spikes and electrographic seizure frequency significantly improved within a day of tDCS. Results are potentially confounded by multiple ongoing changes in medications and treatments. These results might encourage further investigation of tDCS in the critical care setting, but verification by controlled studies will be required.
View details for DOI 10.1111/epi.17514
View details for PubMedID 36661376
Precision medicine in epilepsy.
Progress in molecular biology and translational science
2022; 190 (1): 147-188
Epilepsy is a common neurological disorder affecting over 50 million people worldwide. Although more than 20 new anti-seizure medications have been developed in the past three decades, about one-third of patients still experience recurrent seizures. The heterogeneity of epilepsy types and the highly variable inter-individual response to the therapies makes disease management challenging. A precision medicine approach of treatment for epilepsy patients that considers individual patient characteristics has long been advocated. With advances in DNA sequencing technology, it has been estimated than >30% of all epilepsy syndromes have genetic components. Here we summarize recent approaches in genetic testing and current personalized treatments that are already applicable in genetic epilepsy syndromes. We also discuss current precision therapy utilized in personalized pharmacogenomics, as well as tailored treatment with neuromodulation for epilepsy patients. In the near future, we envision precision medicine in epilepsy will be applicable on a large scale involving not only targeted therapies, but also diagnosis, prognosis, and comorbidity management.
View details for DOI 10.1016/bs.pmbts.2022.04.001
View details for PubMedID 36007998
Cryptogenic new-onset refractory status epilepticus (NORSE) following blood transfusion in a patient with severe anemia.
Epileptic disorders : international epilepsy journal with videotape
New-onset refractory status epilepticus (NORSE) is a rare neurological emergency in which a patient without prior seizure disorder develops seemingly unprovoked status epilepticus refractory to treatment. We report the case of a middle-aged woman who developed NORSE after receiving multiple blood transfusions for subacute blood loss anemia secondary to menorrhagia. Although the mechanism is unclear, we propose that sudden changes in blood viscosity and vasogenic tone resulted in cortical edema and irritation. Although seizures have been documented in patients who undergo blood transfusion and develop posterior reversible encephalopathy syndrome (PRES), there was no radiographic evidence of PRES in this case. This is the first reported case of cryptogenic NORSE following blood transfusion.
View details for DOI 10.1684/epd.2021.1267
View details for PubMedID 33881399
Cryptogenic new-onset refractory status epilepticus (NORSE) following blood transfusion in a patient with severe anemia
LIPPINCOTT WILLIAMS & WILKINS. 2020
View details for Web of Science ID 000536058006056