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Buchholz A, Deme P, Betz JF, Brandt J, Haughey N, Cervenka MC. A randomized feasibility trial of the modified Atkins diet in older adults with mild cognitive impairment due to Alzheimer's disease. Front Endocrinol (Lausanne) 2024; 15:1182519. [PMID: 38505743 PMCID: PMC10949529 DOI: 10.3389/fendo.2024.1182519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 02/05/2024] [Indexed: 03/21/2024] Open
Abstract
Background Alzheimer's disease (AD) is increasing in prevalence, but effective treatments for its cognitive impairment remain severely limited. This study investigates the impact of ketone body production through dietary manipulation on memory in persons with mild cognitive impairment due to early AD and explores potential mechanisms of action. Methods We conducted a 12-week, parallel-group, controlled feasibility trial of a ketogenic diet, the modified Atkins diet (MAD), compared to a control diet in patients with cognitive impairments attributed to AD. We administered neuropsychological assessments, including memory tests, and collected blood samples at baseline and after 12 weeks of intervention. We performed untargeted lipidomic and targeted metabolomic analyses on plasma samples to detect changes over time. Results A total of 839 individuals were screened to yield 38 randomized participants, with 20 assigned to receive MAD and 18 assigned to receive a control diet. Due to attrition, only 13 in the MAD arm and nine in the control arm were assessed for the primary endpoint, with two participants meeting ketosis levels used to define MAD adherence criteria. The average change from baseline in the Memory Composite Score was 1.37 (95% CI: -0.87, 4.90) points higher in the MAD group compared to the control group. The effect size of the intervention on baseline MAD change was moderate (Cohen's D = 0.57, 95% CI: -0.67, 1.33). In the 15 participants (nine MAD, six control) assessed for lipidomic and metabolomic-lipidomics and metabolomics, 13 metabolites and 10 lipids showed significant changes from baseline to 12 weeks, including triacylglycerols (TAGs, 50:5, 52:5, and 52:6), sphingomyelins (SM, 44:3, 46:0, 46:3, and 48:1), acetoacetate, fatty acylcarnitines, glycerol-3-phosphate, and hydroxy fatty acids. Conclusions Attrition was greatest between baseline and week 6. All participants retained at week 6 completed the study. Despite low rates of adherence by criteria defined a priori, lipidomic and metabolomic analyses indicate significant changes from baseline in circulating lipids and metabolites between MAD and control participants at 12-week postrandomization, and MAD participants showed greater, albeit nonsignificant, improvement in memory.
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Affiliation(s)
- Alison Buchholz
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Pragney Deme
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Joshua F. Betz
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jason Brandt
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Norman Haughey
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mackenzie C. Cervenka
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
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McDonald TJW, Diaz-Arias L, Vizthum D, Henry-Barron BJ, Cervenka MC. Predictors of elevations in fasting lipid levels in adults with epilepsy on a modified Atkins diet. Seizure 2023; 113:86-92. [PMID: 38006874 DOI: 10.1016/j.seizure.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Ketogenic diet therapies can improve seizure control in patients with drug-resistant epilepsy (DRE). The current study investigated whether dietary fat composition is associated with elevations in serum lipid levels in adults with epilepsy who began a modified Atkins diet (MAD). METHODS Adults with DRE were instructed to follow the MAD. Food records collected at baseline and follow-up were analyzed to extract median daily macro- and micronutrient composition. Total cholesterol (TC), low-density lipoprotein (LDL) cholesterol, triglyceride (TG), high-density lipoprotein (HDL) cholesterol, non-HDL and TC/HDL ratio were measured at baseline and follow-up. RESULTS Study participants initiating MAD showed higher fat intake at 1 month (p<0.001) and 2 months (p<0.001) and lower carbohydrate intake at 1 month (p<0.001) and 2 months (p<0.001) compared to baseline. Study participants also showed higher intake of cholesterol (p<0.001), saturated fatty acid (p<0.001) and monounsaturated fatty acid (p<0.001) over time. Following MAD initiation, study participants showed significant increases in levels of TC (p = 0.007), LDL (p<0.001), and non-HDL (p = 0.009) over time. Dietary intake variables, including cholesterol and fat subtypes, were significantly associated with difference in 1 month TC and LDL levels from baseline but not absolute 1 month lipid values. In a sub-analysis, participants with baseline dyslipidemia showed smaller changes in lipid values during diet use. CONCLUSIONS Adults with DRE starting MAD increased fat intake, particularly saturated and monounsaturated fat subtypes, and reduced carbohydrate intake. Changes in TC and LDL levels 1 month after MAD initiation are associated with dietary intake of cholesterol and fat.
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Affiliation(s)
- Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD 21287, United States.
| | - Luisa Diaz-Arias
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD 21287, United States
| | - Diane Vizthum
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, United States; Department of Behavioral Health and Nutrition, University of Delaware, Newark, DE, United States
| | - Bobbie J Henry-Barron
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, United States
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD 21287, United States
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Dickens AM, Johnson TP, Lamichhane S, Kumar A, Pardo CA, Gutierrez EG, Haughey N, Cervenka MC. Changes in lipids and inflammation in adults with super-refractory status epilepticus on a ketogenic diet. Front Mol Biosci 2023; 10:1173039. [PMID: 37936721 PMCID: PMC10627179 DOI: 10.3389/fmolb.2023.1173039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 10/02/2023] [Indexed: 11/09/2023] Open
Abstract
Introduction: This study aims to test the hypothesis that increased ketone body production resulting from a ketogenic diet (KD) will correlate with reductions in pro-inflammatory cytokines and lipid subspecies and improved clinical outcomes in adults treated with an adjunctive ketogenic diet for super-refractory status epilepticus (SRSE). Methods: Adults (18 years or older) were treated with a 4:1 (fat: carbohydrate and protein) ratio of enteral KD as adjunctive therapy to pharmacologic seizure suppression in SRSE. Blood and urine samples and clinical measurements were collected at baseline (n = 10), after 1 week (n = 8), and after 2 weeks of KD (n = 5). In addition, urine acetoacetate, serum β-hydroxybutyrate, lipidomics, pro-inflammatory cytokines (IL-1β and IL-6), chemokines (CCL3, CCL4, and CXCL13), and clinical measurements were obtained at these three time points. Univariate and multivariate data analyses were performed to determine the correlation between ketone body production and circulating lipids, inflammatory biomarkers, and clinical outcomes. Results: Changes in lipids included an increase in ceramides, mono-hexosylceramide, sphingomyelin, phosphocholine, and phosphoserines, and there was a significant reduction in pro-inflammatory mediators, IL-6 and CXCL13, seen at 1 and 2 weeks of KD. Higher blood β-hydroxybutyrate levels at baseline correlated with better clinical outcomes; however, ketone body production did not correlate with other variables during treatment. Higher chemokine CCL3 levels following treatment correlated with a longer stay in the intensive care unit and a higher modified Rankin Scale score (worse neurologic disability) at discharge and 6-month follow up. Discussion: Adults receiving an adjunctive enteral ketogenic diet for super-refractory status epilepticus exhibit alterations in select pro-inflammatory cytokines and lipid species that may predict their response to treatment.
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Affiliation(s)
- Alex M. Dickens
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, Turku, Finland
- Department of Chemistry, University of Turku, Turku, Finland
| | - Tory P. Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Santosh Lamichhane
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, Turku, Finland
| | - Anupama Kumar
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Carlos A. Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Erie G. Gutierrez
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Norman Haughey
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mackenzie C. Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Cervenka MC. Be a PEACH and Hand Me That Levetiracetam: Seizure Prophylaxis for Spontaneous Intracerebral Hemorrhage. Epilepsy Curr 2023; 23:241-243. [PMID: 37662466 PMCID: PMC10470104 DOI: 10.1177/15357597231174112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
Safety and Efficacy of Prophylactic Levetiracetam for Prevention of Epileptic Seizures in the Acute Phase of Intracerebral Haemorrhage (PEACH): A Randomised, Double-Blind, Placebo-Controlled, Phase 3 Trial Peter-Derex L, Philippeau F, Garnier P, André-Obadia N, Boulogne S, Catenoix H, Convers P, Mazzola L, Gouttard M, Esteban M, Fontaine J, Mechtouff L, Ong E, Cho T-H, Nighoghossian N, Perreton N, Termoz A, Haesebaert J, Schott A-M, Rabilloud M, Pivot C, Dhelens C, Filip A, Berthezène Y, Rheims S, Boutitie F, Derex L. Lancet Neurol . 2022;21(9):781-791. doi:10.1016/S1474-4422(22)00235-6 Background: The incidence of early seizures (occurring within 7 days of stroke onset) after intracerebral haemorrhage reaches 30% when subclinical seizures are diagnosed by continuous EEG. Early seizures might be associated with haematoma expansion and worse neurological outcomes. Current guidelines do not recommend prophylactic antiseizure treatment in this setting. We aimed to assess whether prophylactic levetiracetam would reduce the risk of acute seizures in patients with intracerebral haemorrhage. Methods: The double-blind, randomised, placebo-controlled, phase 3 PEACH trial was conducted at three stroke units in France. Patients (aged 18 years or older) who presented with a non-traumatic intracerebral haemorrhage within 24 h after onset were randomly assigned (1:1) to levetiracetam (intravenous 500 mg every 12 h) or matching placebo. Randomisation was done with a web-based system and stratified by centre and National Institutes of Health Stroke Scale (NIHSS) score at baseline. Treatment was continued for 6 weeks. Continuous EEG was started within 24 h after inclusion and recorded over 48 h. The primary endpoint was the occurrence of at least one clinical seizure within 72 h of inclusion or at least one electrographic seizure recorded on continuous EEG, analysed in the modified intention-to-treat population, which comprised all patients who were randomly assigned to treatment and who had a continuous EEG performed. This trial was registered at ClinicalTrials.gov , NCT02631759, and is now closed. Recruitment was prematurely stopped after 48% of the recruitment target was reached due to a low recruitment rate and cessation of funding. Findings Between June 1, 2017, and April 14, 2020, 50 patients with mild-to-moderate severity intracerebral haemorrhage were included: 24 were assigned to levetiracetam and 26 to placebo. During the first 72 h, a clinical or electrographic seizure was observed in three (16%) of 19 patients in the levetiracetam group versus ten (43%) of 23 patients in the placebo group (odds ratio 0.16, 95% CI 0.03–0.94, p = 0.043). All seizures in the first 72 h were electrographic seizures only. No difference in depression or anxiety reporting was observed between the groups at 1 month or 3 months. Depression was recorded in three (13%) patients who received levetiracetam versus four (15%) patients who received placebo, and anxiety was reported for two (8%) patients versus one (4%) patient. The most common treatment-emergent adverse events in the levetiracetam group versus the placebo group were headache (nine [39%] vs six [24%]), pain (three [13%] vs ten [40%]), and falls (seven [30%] vs four [16%]). The most frequent serious adverse events were neurological deterioration due to the intracerebral haemorrhage (one [4%] vs four [16%]) and severe pneumonia (two [9%] vs two [8%]). No treatment-related death was reported in either group. Interpretation: Levetiracetam might be effective in preventing acute seizures in intracerebral haemorrhage. Larger studies are needed to determine whether seizure prophylaxis improves functional outcome in patients with intracerebral haemorrhage.
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Teixeira FJP, Shannon J, Busl KM, Robinson CP, Ahmed B, Katz J, Miao G, Seckar J, Bruzzone M, Cervenka MC, Maciel CB. Utilization of the ketogenic diet for adults with status epilepticus. Epilepsy Behav 2023; 144:109279. [PMID: 37271018 DOI: 10.1016/j.yebeh.2023.109279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/18/2023] [Accepted: 05/20/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND The ketogenic diet (KD) is a high-fat, low-carbohydrate diet with therapeutic potential in refractory seizures, both in outpatient and inpatient settings. Successful implementation of KD involves a multifaceted, interdisciplinary approach to address anticipated challenges. We sought to characterize the utilization of KD among healthcare providers caring for adults with status epilepticus (SE). METHODS We distributed a web-based survey through professional societies, including the American Academy of Neurology (AAN), Neurocritical Care Society (NCS), American Epilepsy Society (AES), Neuro Anesthesia and Critical Care Society (NACCS), and the Academy of Nutrition and Dietetics (AND), and via research contacts. We asked respondents about practice experience and experience using KD as a treatment for SE. Descriptive statistics and Chi-square tests were used to analyze the results. RESULTS Of 156 respondents, 80% of physicians and 18% of non-physicians reported experience with KD for SE. Anticipated difficulty in achieving ketosis (36.3%), lack of expertise (24.2%), and lack of resources (20.9%) were identified as the most important barriers limiting the utilization of KD. The absence of dietitians (37.1%) or pharmacists (25.7%) support was the most important missing resource. Reasons for stopping KD included perceived ineffectiveness (29.1%), difficulty achieving ketosis (24.6%), and side effects (17.3%). Academic centers had more experience with the use of KD and greater EEG monitoring availability and fewer barriers to its implementation. The need for randomized clinical trials supporting efficacy (36.5%) and better practice guidelines for implementation and maintenance of KD (29.6%) were cited most frequently as factors to increase utilization of KD. CONCLUSION This study identifies important barriers to the utilization of KD as a treatment for SE despite evidence supporting its efficacy in the appropriate clinical context, namely lack of resources and interdisciplinary support, and lack of established practice guidelines. Our results highlight the need for future research to improve understanding of the efficacy and safety of KD along with better interdisciplinary collaborations to increase its utilization.
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Affiliation(s)
- Fernanda J P Teixeira
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL 32611, USA; Department of Neurology, University of Miami, Miami, FL 33136, USA
| | - Jacqueline Shannon
- State University of New York College of Optometry, New York, NY 10036, USA
| | - Katharina M Busl
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL 32611, USA; Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Christopher P Robinson
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL 32611, USA; Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Bakhtawar Ahmed
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL 32611, USA
| | - Jason Katz
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL 32611, USA
| | - Guanhong Miao
- Department of Biostatistics, University of Florida, Gainesville, FL 32611, USA
| | - Jenna Seckar
- University of Florida Health Shands Hospital, Gainesville, FL 32610, USA
| | - Maria Bruzzone
- Department of Neurology, Division of Epilepsy, University of Florida College of Medicine, Gainesville, FL 32611, USA
| | - Mackenzie C Cervenka
- Department of Neurology, Division of Epilepsy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Carolina B Maciel
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL 32611, USA; Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, FL 32611, USA; Department of Neurology, Division of Epilepsy, University of Florida College of Medicine, Gainesville, FL 32611, USA; Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA.
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Muller AL, Diaz-Arias L, Cervenka MC, McDonald TJW. The effect of anti-seizure medications on lipid values in adults with epilepsy. Epilepsy Behav 2023; 144:109260. [PMID: 37244221 DOI: 10.1016/j.yebeh.2023.109260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE Certain anti-seizure medications (ASMs) adversely impact lipid values. Here, we explored the impact of ASMs on lipid values in adults with epilepsy. METHODS A total of 228 adults with epilepsy were divided into four groups based on ASMs used: strong EIASMs, weak EIASMs, non-EIASMs, and no ASMs. Demographic information, epilepsy-specific clinical history, and lipid values were obtained through chart review. RESULTS While there was no significant difference in lipid values between groups, there was a significant difference in the proportion of participants with dyslipidemia. Specifically, more participants exhibited elevated low-density lipoprotein (LDL) level in the strong EIASM group compared to the non-EIASM group (46.7% vs 18%, p < 0.05). In addition, more participants showed elevated LDL level in the weak EIASM group compared to the non-EIASM group (38% vs 18%, p < 0.05). Users of strong EIASMs showed greater odds of high LDL level (OR 5.734, p = 0.005) and high total cholesterol level (OR 4.913, p = 0.008) compared to users of non-EIASMs. When we analyzed the impact of individual ASMs used by more than 15% of the cohort on lipid levels, participants using valproic acid (VPA) showed lower high-density lipoprotein (p = 0.002) and higher triglyceride levels (p = 0.002) compared to participants not using VPA. CONCLUSION Our study demonstrated a difference in the proportion of participants with dyslipidemia between ASM groups. Thus, adults with epilepsy using EIASMs should have careful monitoring of lipid values to address the risk of cardiovascular disease.
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Affiliation(s)
- Ashley L Muller
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Luisa Diaz-Arias
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Jing J, Ge W, Struck AF, Fernandes MB, Hong S, An S, Fatima S, Herlopian A, Karakis I, Halford JJ, Ng MC, Johnson EL, Appavu BL, Sarkis RA, Osman G, Kaplan PW, Dhakar MB, Jayagopal LA, Sheikh Z, Taraschenko O, Schmitt S, Haider HA, Kim JA, Swisher CB, Gaspard N, Cervenka MC, Rodriguez Ruiz AA, Lee JW, Tabaeizadeh M, Gilmore EJ, Nordstrom K, Yoo JY, Holmes MG, Herman ST, Williams JA, Pathmanathan J, Nascimento FA, Fan Z, Nasiri S, Shafi MM, Cash SS, Hoch DB, Cole AJ, Rosenthal ES, Zafar SF, Sun J, Westover MB. Interrater Reliability of Expert Electroencephalographers Identifying Seizures and Rhythmic and Periodic Patterns in EEGs. Neurology 2023; 100:e1737-e1749. [PMID: 36460472 PMCID: PMC10136018 DOI: 10.1212/wnl.0000000000201670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 10/25/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The validity of brain monitoring using electroencephalography (EEG), particularly to guide care in patients with acute or critical illness, requires that experts can reliably identify seizures and other potentially harmful rhythmic and periodic brain activity, collectively referred to as "ictal-interictal-injury continuum" (IIIC). Previous interrater reliability (IRR) studies are limited by small samples and selection bias. This study was conducted to assess the reliability of experts in identifying IIIC. METHODS This prospective analysis included 30 experts with subspecialty clinical neurophysiology training from 18 institutions. Experts independently scored varying numbers of ten-second EEG segments as "seizure (SZ)," "lateralized periodic discharges (LPDs)," "generalized periodic discharges (GPDs)," "lateralized rhythmic delta activity (LRDA)," "generalized rhythmic delta activity (GRDA)," or "other." EEGs were performed for clinical indications at Massachusetts General Hospital between 2006 and 2020. Primary outcome measures were pairwise IRR (average percent agreement [PA] between pairs of experts) and majority IRR (average PA with group consensus) for each class and beyond chance agreement (κ). Secondary outcomes were calibration of expert scoring to group consensus, and latent trait analysis to investigate contributions of bias and noise to scoring variability. RESULTS Among 2,711 EEGs, 49% were from women, and the median (IQR) age was 55 (41) years. In total, experts scored 50,697 EEG segments; the median [range] number scored by each expert was 6,287.5 [1,002, 45,267]. Overall pairwise IRR was moderate (PA 52%, κ 42%), and majority IRR was substantial (PA 65%, κ 61%). Noise-bias analysis demonstrated that a single underlying receiver operating curve can account for most variation in experts' false-positive vs true-positive characteristics (median [range] of variance explained ([Formula: see text]): 95 [93, 98]%) and for most variation in experts' precision vs sensitivity characteristics ([Formula: see text]: 75 [59, 89]%). Thus, variation between experts is mostly attributable not to differences in expertise but rather to variation in decision thresholds. DISCUSSION Our results provide precise estimates of expert reliability from a large and diverse sample and a parsimonious theory to explain the origin of disagreements between experts. The results also establish a standard for how well an automated IIIC classifier must perform to match experts. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that an independent expert review reliably identifies ictal-interictal injury continuum patterns on EEG compared with expert consensus.
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Affiliation(s)
- Jin Jing
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Wendong Ge
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Aaron F Struck
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Marta Bento Fernandes
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Shenda Hong
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sungtae An
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Safoora Fatima
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Aline Herlopian
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Ioannis Karakis
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jonathan J Halford
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Marcus C Ng
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Emily L Johnson
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Brian L Appavu
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Rani A Sarkis
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Gamaleldin Osman
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Peter W Kaplan
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Monica B Dhakar
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Lakshman Arcot Jayagopal
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Zubeda Sheikh
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Olga Taraschenko
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sarah Schmitt
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Hiba A Haider
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jennifer A Kim
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Christa B Swisher
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Nicolas Gaspard
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Mackenzie C Cervenka
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Andres A Rodriguez Ruiz
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jong Woo Lee
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Mohammad Tabaeizadeh
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Emily J Gilmore
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Kristy Nordstrom
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Ji Yeoun Yoo
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Manisha G Holmes
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Susan T Herman
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jennifer A Williams
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jay Pathmanathan
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Fábio A Nascimento
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Ziwei Fan
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Samaneh Nasiri
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Mouhsin M Shafi
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sydney S Cash
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Daniel B Hoch
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Andrew J Cole
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Eric S Rosenthal
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sahar F Zafar
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jimeng Sun
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - M Brandon Westover
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL.
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Jing J, Ge W, Hong S, Fernandes MB, Lin Z, Yang C, An S, Struck AF, Herlopian A, Karakis I, Halford JJ, Ng MC, Johnson EL, Appavu BL, Sarkis RA, Osman G, Kaplan PW, Dhakar MB, Arcot Jayagopal L, Sheikh Z, Taraschenko O, Schmitt S, Haider HA, Kim JA, Swisher CB, Gaspard N, Cervenka MC, Rodriguez Ruiz AA, Lee JW, Tabaeizadeh M, Gilmore EJ, Nordstrom K, Yoo JY, Holmes MG, Herman ST, Williams JA, Pathmanathan J, Nascimento FA, Fan Z, Nasiri S, Shafi MM, Cash SS, Hoch DB, Cole AJ, Rosenthal ES, Zafar SF, Sun J, Westover MB. Development of Expert-Level Classification of Seizures and Rhythmic and Periodic Patterns During EEG Interpretation. Neurology 2023; 100:e1750-e1762. [PMID: 36878708 PMCID: PMC10136013 DOI: 10.1212/wnl.0000000000207127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 01/12/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Seizures (SZs) and other SZ-like patterns of brain activity can harm the brain and contribute to in-hospital death, particularly when prolonged. However, experts qualified to interpret EEG data are scarce. Prior attempts to automate this task have been limited by small or inadequately labeled samples and have not convincingly demonstrated generalizable expert-level performance. There exists a critical unmet need for an automated method to classify SZs and other SZ-like events with expert-level reliability. This study was conducted to develop and validate a computer algorithm that matches the reliability and accuracy of experts in identifying SZs and SZ-like events, known as "ictal-interictal-injury continuum" (IIIC) patterns on EEG, including SZs, lateralized and generalized periodic discharges (LPD, GPD), and lateralized and generalized rhythmic delta activity (LRDA, GRDA), and in differentiating these patterns from non-IIIC patterns. METHODS We used 6,095 scalp EEGs from 2,711 patients with and without IIIC events to train a deep neural network, SPaRCNet, to perform IIIC event classification. Independent training and test data sets were generated from 50,697 EEG segments, independently annotated by 20 fellowship-trained neurophysiologists. We assessed whether SPaRCNet performs at or above the sensitivity, specificity, precision, and calibration of fellowship-trained neurophysiologists for identifying IIIC events. Statistical performance was assessed by the calibration index and by the percentage of experts whose operating points were below the model's receiver operating characteristic curves (ROCs) and precision recall curves (PRCs) for the 6 pattern classes. RESULTS SPaRCNet matches or exceeds most experts in classifying IIIC events based on both calibration and discrimination metrics. For SZ, LPD, GPD, LRDA, GRDA, and "other" classes, SPaRCNet exceeds the following percentages of 20 experts-ROC: 45%, 20%, 50%, 75%, 55%, and 40%; PRC: 50%, 35%, 50%, 90%, 70%, and 45%; and calibration: 95%, 100%, 95%, 100%, 100%, and 80%, respectively. DISCUSSION SPaRCNet is the first algorithm to match expert performance in detecting SZs and other SZ-like events in a representative sample of EEGs. With further development, SPaRCNet may thus be a valuable tool for an expedited review of EEGs. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that among patients with epilepsy or critical illness undergoing EEG monitoring, SPaRCNet can differentiate (IIIC) patterns from non-IIIC events and expert neurophysiologists.
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Affiliation(s)
- Jin Jing
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Wendong Ge
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Shenda Hong
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Marta Bento Fernandes
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Zhen Lin
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Chaoqi Yang
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Sungtae An
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Aaron F Struck
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Aline Herlopian
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Ioannis Karakis
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jonathan J Halford
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Marcus C Ng
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Emily L Johnson
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Brian L Appavu
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Rani A Sarkis
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Gamaleldin Osman
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Peter W Kaplan
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Monica B Dhakar
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Lakshman Arcot Jayagopal
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Zubeda Sheikh
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Olga Taraschenko
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Sarah Schmitt
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Hiba A Haider
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jennifer A Kim
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Christa B Swisher
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Nicolas Gaspard
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Mackenzie C Cervenka
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Andres A Rodriguez Ruiz
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jong Woo Lee
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Mohammad Tabaeizadeh
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Emily J Gilmore
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Kristy Nordstrom
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Ji Yeoun Yoo
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Manisha G Holmes
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Susan T Herman
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jennifer A Williams
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jay Pathmanathan
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Fábio A Nascimento
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Ziwei Fan
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Samaneh Nasiri
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Mouhsin M Shafi
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Sydney S Cash
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Daniel B Hoch
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Andrew J Cole
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Eric S Rosenthal
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Sahar F Zafar
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jimeng Sun
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - M Brandon Westover
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA.
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Husari KS, Solnes L, Cervenka MC, Venkatesan A, Probasco J, Ritzl EK, Johnson EL. EEG Correlates of Qualitative Hypermetabolic FDG-PET in Patients With Neurologic Disorders. Neurol Clin Pract 2023; 13:e200135. [PMID: 36936394 PMCID: PMC10022725 DOI: 10.1212/cpj.0000000000200135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/28/2022] [Indexed: 03/16/2023]
Abstract
Background and Objectives Case reports and case series have described fluorodeoxyglucose (FDG)-PET findings in critically ill patients with rhythmic or periodic EEG patterns, with one reporting that metabolic activity increases with increasing lateralized periodic discharge (LPD) frequency. However, larger studies examining the relationship between FDG-PET hypermetabolism and rhythmic or periodic EEG patterns are lacking. The goal of this study was to investigate the association of FDG-PET hypermetabolism with electroencephalographic features in patients with neurologic disorders. Methods This was a single-center, retrospective study of adult patients admitted with acute neurologic symptoms who underwent FDG-PET imaging and EEG monitoring within 24 hours. Subjects were divided into 2 groups based on their FDG-PET metabolism pattern: hypermetabolic activity vs hypometabolic or normal metabolic activity. Chi-square tests and logistic regression were used to determine the relationship of FDG-PET metabolism and EEG findings. Results Sixty patients met the inclusion criteria and underwent 63 FDG-PET studies and EEGs. Twenty-seven studies (43%) showed hypermetabolism while 36 studies (57%) showed either hypometabolism or no abnormalities on FDG-PET. Subjects with hypermetabolic FDG-PET were more likely to have electrographic seizures (44% vs 8%, p = 0.001) and LPDs with/without seizures (44% vs 14%, p = 0.007), but not other rhythmic or periodic EEG patterns (lateralized rhythmic delta activity, generalized periodic discharges, or generalized rhythmic delta activity). Subjects with hypermetabolism and LPDs were more likely to have concurrent electrographic seizures (58% vs 0%, p = 0.03), fast activity associated with the discharges (67% vs 0, p = 0.01), or spike morphology (67% vs 0, p = 0.03), compared with subjects with hypometabolic FDG-PET and LPDs. Discussion Adults admitted with acute neurologic symptoms who had hypermetabolic FDG-PET were more likely to show electrographic seizures and LPDs, but not other rhythmic or periodic EEG patterns, compared with those with hypometabolic FDG-PET. Subjects with hypermetabolic FDG-PET and LPDs were more likely to have LPDs with concurrent electrographic seizures, LPDs with a spike morphology, and LPDs +F, compared with subjects with hypometabolic FDG-PET.
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Affiliation(s)
- Khalil S Husari
- Department of Neurology (KSH, MCC, EKR, ELJ), Comprehensive Epilepsy Center, Department of Radiology and Radiological Science (LS), Division of Neuroimmunology and Neurological Infections (AV), and Division of Advanced Clinical Neurology (JP), Department of Neurology, and Department of Anesthesiology and Critical Care Medicine (EKR), Johns Hopkins University, Baltimore, MD
| | - Lilja Solnes
- Department of Neurology (KSH, MCC, EKR, ELJ), Comprehensive Epilepsy Center, Department of Radiology and Radiological Science (LS), Division of Neuroimmunology and Neurological Infections (AV), and Division of Advanced Clinical Neurology (JP), Department of Neurology, and Department of Anesthesiology and Critical Care Medicine (EKR), Johns Hopkins University, Baltimore, MD
| | - Mackenzie C Cervenka
- Department of Neurology (KSH, MCC, EKR, ELJ), Comprehensive Epilepsy Center, Department of Radiology and Radiological Science (LS), Division of Neuroimmunology and Neurological Infections (AV), and Division of Advanced Clinical Neurology (JP), Department of Neurology, and Department of Anesthesiology and Critical Care Medicine (EKR), Johns Hopkins University, Baltimore, MD
| | - Arun Venkatesan
- Department of Neurology (KSH, MCC, EKR, ELJ), Comprehensive Epilepsy Center, Department of Radiology and Radiological Science (LS), Division of Neuroimmunology and Neurological Infections (AV), and Division of Advanced Clinical Neurology (JP), Department of Neurology, and Department of Anesthesiology and Critical Care Medicine (EKR), Johns Hopkins University, Baltimore, MD
| | - John Probasco
- Department of Neurology (KSH, MCC, EKR, ELJ), Comprehensive Epilepsy Center, Department of Radiology and Radiological Science (LS), Division of Neuroimmunology and Neurological Infections (AV), and Division of Advanced Clinical Neurology (JP), Department of Neurology, and Department of Anesthesiology and Critical Care Medicine (EKR), Johns Hopkins University, Baltimore, MD
| | - Eva K Ritzl
- Department of Neurology (KSH, MCC, EKR, ELJ), Comprehensive Epilepsy Center, Department of Radiology and Radiological Science (LS), Division of Neuroimmunology and Neurological Infections (AV), and Division of Advanced Clinical Neurology (JP), Department of Neurology, and Department of Anesthesiology and Critical Care Medicine (EKR), Johns Hopkins University, Baltimore, MD
| | - Emily L Johnson
- Department of Neurology (KSH, MCC, EKR, ELJ), Comprehensive Epilepsy Center, Department of Radiology and Radiological Science (LS), Division of Neuroimmunology and Neurological Infections (AV), and Division of Advanced Clinical Neurology (JP), Department of Neurology, and Department of Anesthesiology and Critical Care Medicine (EKR), Johns Hopkins University, Baltimore, MD
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10
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Cervenka MC. Keto Is Not Just for Kids: A Randomized Trial of a Modified Atkins Diet for Adolescents and Adults With Anti-Seizure Medication-Resistant Epilepsy. Epilepsy Curr 2023. [DOI: 10.1177/15357597231157488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
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11
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Sanders JS, Pillai RLI, Sturley R, Sillau S, Asato MR, Aravamuthan BR, Bonuck K, Cervenka MC, Hammond N, Siegel JF, Siasoco V, Margolis BA. Impact of the COVID-19 Pandemic on the Behavioral Health of People With Intellectual and Developmental Disabilities. Psychiatr Serv 2022; 73:1389-1392. [PMID: 35734865 DOI: 10.1176/appi.ps.202100524] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined how the COVID-19 pandemic affected the behavioral health of people with intellectual and developmental disabilities (IDD). METHODS A modified version of the Coronavirus Health Impact Survey-Adapted for Autism and Related Neurodevelopmental Conditions was sent to the authors' clinical networks and IDD-affiliated organizations from March to June 2021. RESULTS In total, 437 people with IDD or their caregivers responded to the survey. Diagnoses included intellectual disability (51%) and autism spectrum disorder (48%). More than half (52%) of respondents reported worsened mental health. Losing access to services correlated with declining mental health. Interventions suggested to improve behavioral health included more time with friends and family (68%), more time outdoors (61%), and access to community activities (59%). CONCLUSIONS COVID-19 affected the behavioral health of individuals with IDD. Survey results highlight the opportunity to leverage physical activity and pandemic-safe social supports as accessible means to mitigate gaps in services.
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Affiliation(s)
- Jessica Solomon Sanders
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Rajapillai L I Pillai
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Rachel Sturley
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Stefan Sillau
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Miya R Asato
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Bhooma R Aravamuthan
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Karen Bonuck
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Mackenzie C Cervenka
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Nancy Hammond
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Joanne F Siegel
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Vincent Siasoco
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
| | - Benjamin A Margolis
- Department of Pediatrics (Sanders) and Department of Neurology (Sanders, Sillau), University of Colorado School of Medicine, Aurora; University of Massachusetts Chan Medical School-Baystate, Springfield (Pillai); Program in Humanistic Studies, Princeton University, Princeton, New Jersey (Sturley); Kennedy Krieger Institute (Asato) and Adult Epilepsy Diet Center (Cervenka), Johns Hopkins School of Medicine, Baltimore; Institute of Clinical and Translational Sciences, Washington University School of Medicine, St. Louis (Aravamuthan); Department of Pediatrics, Albert Einstein College of Medicine, New York City (Bonuck, Siegel, Siasoco); Department of Neurology, University of Kansas Medical Center, Kansas City (Hammond); Access: Supports for Living, Middletown, New York (Margolis)
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Cervenka MC. Let’s Talk About Sex and Juvenile Myoclonic Epilepsy. Epilepsy Curr 2022; 22:356-358. [DOI: 10.1177/15357597221120487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
[Box: see text]
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13
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Diaz-Arias LA, Henry-Barron BJ, Buchholz A, Cervenka MC. Positive impact of a modified Atkins diet on cognition, seizure control, and abnormal movements in an adult with glucose transporter type 1 deficiency syndrome: case report. Neurol Sci 2022; 43:3449-3452. [DOI: 10.1007/s10072-022-05973-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022]
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Ehrens D, Cervenka MC, Bergey GK, Jouny CC. Dynamic training of a novelty classifier algorithm for real-time detection of early seizure onset. Clin Neurophysiol 2022; 135:85-95. [PMID: 35065325 PMCID: PMC8857071 DOI: 10.1016/j.clinph.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 11/19/2021] [Accepted: 12/26/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop an adaptive framework for seizure detection in real-time that is practical to use in the Epilepsy Monitoring Unit (EMU) as a warning signal, and whose output helps characterize epileptiform activity. METHODS Our algorithm was tested on intracranial EEG from epilepsy patients admitted to the EMU for presurgical evaluation. Our framework uses a one-class Support Vector Machine (SVM) that is being trained dynamically according to past activity in all available channels to classify the novelty of the current activity. In this study we compared multiple configurations using a one-class SVM to assess if there is significance over specific neural features or electrode locations. RESULTS Our results show that the algorithm reaches a sensitivity of 87% for early-onset seizure detection and of 97.7% as a generic seizure detection. CONCLUSIONS Our algorithm is capable of running in real-time and achieving a high performance for early seizure-onset detection with a low false positive rate and robustness in detection of different type of seizure-onset patterns. SIGNIFICANCE This algorithm offers a solution to warning systems in the EMU as well as a tool for seizure characterization during post-hoc analysis of intracranial EEG data for surgical resection of the epileptogenic network.
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Affiliation(s)
- Daniel Ehrens
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Mackenzie C. Cervenka
- Department of Neurology, Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - Gregory K. Bergey
- Department of Neurology, Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - Christophe C. Jouny
- Department of Neurology, Johns Hopkins University School of
Medicine, Baltimore, MD, USA
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15
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Cervenka MC, Wood S, Bagary M, Balabanov A, Bercovici E, Brown MG, Devinsky O, Di Lorenzo C, Doherty CP, Felton E, Healy LA, Klein P, Kverneland M, Lambrechts D, Langer J, Nathan J, Munn J, Nguyen P, Phillips M, Roehl K, Tanner A, Williams C, Zupec-Kania B. International Recommendations for the Management of Adults Treated With Ketogenic Diet Therapies. Neurol Clin Pract 2021; 11:385-397. [PMID: 34840865 PMCID: PMC8610544 DOI: 10.1212/cpj.0000000000001007] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 10/16/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate current clinical practices and evidence-based literature to establish preliminary recommendations for the management of adults using ketogenic diet therapies (KDTs). METHODS A 12-topic survey was distributed to international experts on KDTs in adults consisting of neurologists and dietitians at medical institutions providing KDTs to adults with epilepsy and other neurologic disorders. Panel survey responses were tabulated by the authors to determine the common and disparate practices between institutions and to compare these practices in adults with KDT recommendations in children and the medical literature. Recommendations are based on a combination of clinical evidence and expert opinion regarding management of KDTs. RESULTS Surveys were obtained from 20 medical institutions with >2,000 adult patients treated with KDTs for epilepsy or other neurologic disorders. Common side effects reported are similar to those observed in children, and recommendations for management are comparable with important distinctions, which are emphasized. Institutions differ with regard to recommended biochemical assessment, screening, monitoring, and concern for long-term side effects, and further investigation is warranted to determine the optimal clinical management. Differences also exist between screening and monitoring practices among adult and pediatric providers. CONCLUSIONS KDTs may be safe and effective in treating adults with drug-resistant epilepsy, and there is emerging evidence supporting the use in other adult neurologic disorders and general medical conditions as well. Therefore, expert recommendations to guide optimal care are critical as well as further evidence-based investigation.
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Affiliation(s)
- Mackenzie C Cervenka
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Susan Wood
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Manny Bagary
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Antoaneta Balabanov
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Eduard Bercovici
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Mesha-Gay Brown
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Orrin Devinsky
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Cherubino Di Lorenzo
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Colin P Doherty
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Elizabeth Felton
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Laura A Healy
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Pavel Klein
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Magnhild Kverneland
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Danielle Lambrechts
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Jennifer Langer
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Janak Nathan
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Jude Munn
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Patty Nguyen
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Matthew Phillips
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Kelly Roehl
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Adrianna Tanner
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Clare Williams
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
| | - Beth Zupec-Kania
- Department of Neurology (MCC), Johns Hopkins University School of Medicine, Baltimore, MD; Matthew's Friends Clinics for Ketogenic Dietary Therapies (SW), Lingfield, Surrey, United Kingdom; Complex Epilepsy and Sleep Service (MB, JM), The Barberry, Birmingham, United Kingdom; Department of Neurology (AB, KR), Rush University Medical Center, Chicago, IL; Department of Neurology (EB), University of Toronto, Ontario, Canada; Department of Neurology (M-GB), University of Colorado, Denver; Department of Neurology (OD), New York University School of Medicine; Department of Medico-Surgical Sciences and Biotechnologies (CDL), Sapienza University of Rome Polo Pontino, Italy; Academic Unit of Neurology (CPD), Trinity College Dublin & FutureNeuro, Ireland; Department of Neurology (EF), UW Health, Madison; Department of Clinical Nutrition (LAH), St James' Hospital, Dublin, Ireland; Mid-Atlantic Epilepsy and Sleep Center (PK), Bethesda, MD; National Center for Epilepsy (MK), Oslo, Norway; Department of Neurology (DL), Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Center, Heeze, The Netherlands; Department of Neurology (JL), University of Virginia, Charlottesville; Department of Neurology (JN), Shushrusha Hospital, Mumbai, India; Charles Dent Metabolic Unit (PN), University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Neurology (MP), Waikato Hospital, Hamilton, New Zealand; Mercy Health Hauenstein Neurosciences (AT), Grand Rapids, MI; Department of Dietetics and Foodservices (CW), Mater Group, South Brisbane, QLD, Australia; and The Charlie Foundation for Ketogenic Therapies (BZ-K), Santa Monica, CA
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Abstract
INTRODUCTION Aicardi syndrome is a rare neurodevelopmental disorder associated with epilepsy in females. Ketogenic diet therapy represents a possible nonpharmacologic treatment in Aicardi syndrome patients. METHODS All patients with Aicardi syndrome seen at Johns Hopkins Hospital (Baltimore, MD) and Johns Hopkins All Children's Hospital (St Petersburg, FL) treated with ketogenic diet therapy since 1994 were evaluated retrospectively. RESULTS Fifteen patients, ages 4 months to 34 years, were identified. Ten (67%) patients experienced a ≥50% seizure reduction after 3 months, with 3 (20%) having a ≥90% reduction. Only 1 patient was seizure-free for a short period of time. The number of drugs tried prior to ketogenic diet therapy initiation was correlated with ≥50% seizure reduction at 3 months, 5.8 vs 2.6 in responders versus nonresponders (P = .01). In addition, the mean number of drugs actively received also correlated, 3.0 vs 1.2, P = .005. Ketogenic diet therapy was slightly more successful in those without infantile spasms, 78% vs 50%, P = .33. CONCLUSION Ketogenic diet therapy was helpful in Aicardi syndrome, although seizure freedom was rare. It was especially helpful for those who were more drug-resistant and did not have infantile spasms at ketogenic diet therapy onset.
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Affiliation(s)
| | | | - Stacey K Bessone
- Department of Nutrition, Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Eric H Kossoff
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
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Schreck KC, Hsu FC, Berrington A, Henry-Barron B, Vizthum D, Blair L, Kossoff EH, Easter L, Whitlow CT, Barker PB, Cervenka MC, Blakeley JO, Strowd RE. Feasibility and Biological Activity of a Ketogenic/Intermittent-Fasting Diet in Patients With Glioma. Neurology 2021; 97:e953-e963. [PMID: 34233941 DOI: 10.1212/wnl.0000000000012386] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/28/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To examine the feasibility, safety, systemic biological activity, and cerebral activity of a ketogenic dietary intervention in patients with glioma. METHODS 25 patients with biopsy-confirmed WHO Grade 2-4 astrocytoma with stable disease following adjuvant chemotherapy were enrolled in an 8-week GLioma Atkins-based Diet (GLAD). GLAD consisted of 2 fasting days (calories<20% calculated estimated needs) interleaved between 5 modified Atkins diet days (net carbohydrates≤20 gm/day) each week. The primary outcome was dietary adherence by food records. Markers of systemic and cerebral activity included weekly urine ketones, serum insulin, glucose, hemoglobin A1c, IGF-1, and MR spectroscopy at baseline and week 8. RESULTS 21 patients completed the study (84%). 80% of patients reached ≥40 mg/dL urine acetoacetate during the study. 48% of patients were adherent by food record. The diet was well-tolerated with two grade 3 adverse events (neutropenia, seizure). Measures of systemic activity including hemoglobin A1c, insulin, and fat body mass decreased significantly, while lean body mass increased. MR spectroscopy demonstrated increased ketone concentrations (β-hydroxybutyrate (bHB) and acetone (Ace)) in both lesional and contralateral brain, compared to baseline. Average ketonuria correlated with cerebral ketones in lesional (tumor) and contralateral brain (bHB Rs 0.52, p=0.05). Sub-group analysis of IDH-mutant glioma showed no differences in cerebral metabolites after controlling for ketonuria. CONCLUSIONS The GLAD dietary intervention, while demanding, produced meaningful ketonuria, and significant systemic and cerebral metabolic changes in participants. Ketonuria in participants correlated with cerebral ketone concentration and appear to be a better indicator of systemic activity than patient-reported food records.
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Affiliation(s)
- Karisa C Schreck
- Departments of Neurology, Oncology, and Neurosurgery Johns Hopkins University School of Medicine, Baltimore, MD
| | - Fang-Chi Hsu
- Department of Biostatistics and Data Science Wake Forest School of Medicine, Winston-Salem, NC
| | - Adam Berrington
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD.,Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, UK
| | - Bobbie Henry-Barron
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Diane Vizthum
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lindsay Blair
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric H Kossoff
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Linda Easter
- Clinical Research Unit, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christopher T Whitlow
- Departments of Radiology, Biostatistics and Data Science, Biomedical Engineering, and Clinical and Translational Science Institute, Wake Forest School of Medicine, Winston-Salem, NC
| | - Peter B Barker
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jaishri O Blakeley
- Departments of Neurology, Oncology, and Neurosurgery Johns Hopkins University School of Medicine, Baltimore, MD
| | - Roy E Strowd
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; .,Departments of Neurology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC
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Di Lorenzo C, Ballerini G, Barbanti P, Bernardini A, D’Arrigo G, Egeo G, Frediani F, Garbo R, Pierangeli G, Prudenzano MP, Rebaudengo N, Semeraro G, Sirianni G, Valente M, Coppola G, Cervenka MC, Spera G. Applications of Ketogenic Diets in Patients with Headache: Clinical Recommendations. Nutrients 2021; 13:2307. [PMID: 34371817 PMCID: PMC8308539 DOI: 10.3390/nu13072307] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 02/07/2023] Open
Abstract
Headaches are among the most prevalent and disabling neurologic disorders and there are several unmet needs as current pharmacological options are inadequate in treating patients with chronic headache, and a growing interest focuses on nutritional approaches as non-pharmacological treatments. Among these, the largest body of evidence supports the use of the ketogenic diet (KD). Exactly 100 years ago, KD was first used to treat drug-resistant epilepsy, but subsequent applications of this diet also involved other neurological disorders. Evidence of KD effectiveness in migraine emerged in 1928, but in the last several year's different groups of researchers and clinicians began utilizing this therapeutic option to treat patients with drug-resistant migraine, cluster headache, and/or headache comorbid with metabolic syndrome. Here we describe the existing evidence supporting the potential benefits of KDs in the management of headaches, explore the potential mechanisms of action involved in the efficacy in-depth, and synthesize results of working meetings of an Italian panel of experts on this topic. The aim of the working group was to create a clinical recommendation on indications and optimal clinical practice to treat patients with headaches using KDs. The results we present here are designed to advance the knowledge and application of KDs in the treatment of headaches.
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Affiliation(s)
- Cherubino Di Lorenzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, 04100 Latina, Italy;
| | - Giovanna Ballerini
- Multidisciplinary Center for Pain Therapy, Piero Palagi Hospital, USL Toscana Centro, 50122 Florence, Italy;
| | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, 00163 Rome, Italy; (P.B.); (G.E.)
- Department of Neuroscience and Rehabilitation, San Raffaele University, 00163 Rome, Italy
| | - Andrea Bernardini
- Clinical Neurology Unit, Misericordia University Hospital, Santa Maria Della Misericordia University Hospital, 33100 Udine, Italy; (A.B.); (R.G.); (M.V.)
| | - Giacomo D’Arrigo
- Headache Center, Neurology & Stroke Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20142 Milan, Italy; (G.D.); (F.F.)
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele Pisana, 00163 Rome, Italy; (P.B.); (G.E.)
| | - Fabio Frediani
- Headache Center, Neurology & Stroke Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20142 Milan, Italy; (G.D.); (F.F.)
| | - Riccardo Garbo
- Clinical Neurology Unit, Misericordia University Hospital, Santa Maria Della Misericordia University Hospital, 33100 Udine, Italy; (A.B.); (R.G.); (M.V.)
| | - Giulia Pierangeli
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy;
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, 40127 Bologna, Italy
| | - Maria Pia Prudenzano
- Headache Center, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, 70124 Bari, Italy;
| | | | - Grazia Semeraro
- Associazione Eupraxia, Dietary Section, 00171 Rome, Italy; (G.S.); (G.S.)
| | - Giulio Sirianni
- Associazione Eupraxia, Dietary Section, 00171 Rome, Italy; (G.S.); (G.S.)
| | - Mariarosaria Valente
- Clinical Neurology Unit, Misericordia University Hospital, Santa Maria Della Misericordia University Hospital, 33100 Udine, Italy; (A.B.); (R.G.); (M.V.)
- Neurology Unit, Department of Medicine (DAME), University of Udine, Piazzale Santa Maria Della Misericordia 15, 33100 Udine, Italy
| | - Gianluca Coppola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, 04100 Latina, Italy;
| | - Mackenzie C. Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
| | - Giovanni Spera
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, 00161 Rome, Italy;
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Felton EA, Henry-Barron BJ, Jan AK, Shegelman A, Faltersack K, Vizthum D, Cervenka MC. The Feasibility and Tolerability of Medium Chain Triglycerides in Women with a Catamenial Seizure Pattern on the Modified Atkins Diet. Nutrients 2021; 13:2261. [PMID: 34208933 PMCID: PMC8308415 DOI: 10.3390/nu13072261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 12/01/2022] Open
Abstract
Ketogenic diet therapy (KDT), particularly modified Atkins diet (MAD), is increasingly recognized as a treatment for adults with epilepsy. Women with epilepsy (WWE) comprise 50% of people with epilepsy and approximately one in three have catamenial epilepsy. The purpose of this study was to determine whether adding a medium chain triglyceride emulsion to MAD to target catamenial seizures was feasible and well-tolerated. This was a prospective two-center study of pre-menopausal WWE with a catamenial seizure pattern on MAD. After a 1-month baseline interval with no changes in treatment, participants consumed betaquik® (Vitaflo International Ltd.) for 10 days each menstrual cycle starting 2 days prior to and encompassing the primary catamenial seizure pattern for five cycles. Participants recorded seizures, ketones, and menses, and completed surveys measuring tolerability. Sixteen women aged 20-50 years (mean 32) were enrolled and 13 (81.2%) completed the study. There was 100% adherence for consuming betaquik® in the women who completed the study and overall intervention adherence rate including the participants that dropped out was 81.2%. The most common side effects attributed to MAD alone prior to starting betaquik® were constipation and nausea, whereas abdominal pain, diarrhea, and nausea were reported after adding betaquik®. The high adherence rate and acceptable tolerability of betaquik® shows feasibility for future studies evaluating KDT-based treatments for catamenial seizures.
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Affiliation(s)
- Elizabeth A. Felton
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
| | - Bobbie J. Henry-Barron
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA; (B.J.H.-B.); (D.V.)
| | - Amanda K. Jan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.K.J.); (A.S.); (M.C.C.)
| | - Abigail Shegelman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.K.J.); (A.S.); (M.C.C.)
| | - Kelly Faltersack
- Department of Clinical Nutrition Services, UW Health, Madison, WI 53792, USA;
| | - Diane Vizthum
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA; (B.J.H.-B.); (D.V.)
| | - Mackenzie C. Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.K.J.); (A.S.); (M.C.C.)
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20
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Husari KS, Cervenka MC. Ketogenic Diet Therapy for the Treatment of Post-encephalitic and Autoimmune-Associated Epilepsies. Front Neurol 2021; 12:624202. [PMID: 34220664 PMCID: PMC8242936 DOI: 10.3389/fneur.2021.624202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/19/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction: Acute Encephalitis is associated with a high risk of acute symptomatic seizures, status epilepticus, and remote symptomatic epilepsy. Ketogenic diet therapies (KDT) have been established as a feasible and safe adjunctive management of refractory- and super-refractory status epilepticus. However, the role of KDT in the chronic management of Post-encephalitic epilepsy (PE) and autoimmune-associated epilepsy (AE) is unknown. This study aims to investigate the use of KDT in patients with PE and AE. Methods: A retrospective single-center case series examining adult patients with PE and AE treated with the modified Atkins diet (MAD), a KDT commonly used by adults with drug-resistant epilepsy. Results: Ten patients with PE and AE who were treated with adjunctive MAD were included. Four patients had either confirmed or presumed viral encephalitis, five patients had seronegative AE, and one patient had GAD65 AE. The median latency between starting MAD and onset of encephalitis was 6 years (IQR: 1–10). The median duration of MAD was 10 months (IQR: 3.75–36). Three patients (30%) became seizure-free, one patient (10%) achieved 90% seizure freedom, and three patients (30%) achieved a 50–75% reduction in their baseline seizure frequency, while three patients (30%) had no significant benefit. Overall, seven patients (70%) achieved ≥50% seizure reduction. Conclusion: In addition to its established role in the treatment of RSE, KDT may be a safe and feasible option for the treatment of chronic PE and AE, particularly in those with prior history of SE. Prospective studies are warranted to explore the efficacy of KDT in management of patients with PE and AE.
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Affiliation(s)
- Khalil S Husari
- Department of Neurology, Johns Hopkins Comprehensive Epilepsy Center, Johns Hopkins University, Baltimore, MD, United States
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins Comprehensive Epilepsy Center, Johns Hopkins University, Baltimore, MD, United States
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21
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Shegelman A, Carson KA, McDonald TJW, Henry-Barron BJ, Diaz-Arias LA, Cervenka MC. The psychiatric effects of ketogenic diet therapy on adults with chronic epilepsy. Epilepsy Behav 2021; 117:107807. [PMID: 33610104 DOI: 10.1016/j.yebeh.2021.107807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/16/2021] [Accepted: 01/16/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Patients with epilepsy are known to exhibit high rates of comorbid psychiatric disorders such as depression, anxiety, and other mood disorders. Little is known about the psychiatric effects of a ketogenic diet therapy (KDT) on adults with epilepsy. The objective of this study was to better understand the relationship between KDT and psychological state based on depressive and anxiety symptoms in adults with chronic epilepsy. METHODS Adults at the Johns Hopkins Adult Epilepsy Diet Center on a modified Atkins diet (MAD) for at least one month were surveyed retrospectively. Adults who were diet naïve were given a baseline survey and an additional survey after 3 months or more on MAD. Surveys included validated measures of depressive and anxiety symptoms as well as their severity. Participant demographics, seizure frequency, and use of concomitant antiseizure drugs (ASDs), chronic anxiolytics (excluding as-needed benzodiazepines for seizure rescue only), and/or antidepressant drugs were extracted from electronic medical records. RESULTS One-hundred participants aged 19-75 enrolled in the study. Sixty participants filled out a single retrospective survey. Of 40 diet naïve participants who filled out a baseline prospective survey, 19 completed a follow-up survey while on MAD and 21 participants were lost to follow-up. Longer diet duration was significantly associated with fewer anxiety and depressive symptoms, based on psychiatric measure scores, in retrospective study participants. Lower seizure frequency was also significantly associated with less anxiety symptoms in the retrospective cohort. Prospective study participants did not experience significant change in anxiety or depressive symptoms on the diet. There was a significant correlation between higher ketone level and responder rate (≥50% seizure reduction) in the prospective cohort, although no correlation between ketone level and change in psychiatric symptoms was seen. SIGNIFICANCE Psychiatric comorbidity among patients with epilepsy is quite common and can be influenced by multiple factors such as seizure frequency, the use of various ASDs, social factors, and underlying etiology. Although ketogenic diet therapies have been in clinical use for one century, the psychiatric impacts have been insufficiently explored. This study provides preliminary evidence that KDT may have a positive impact on psychological state independent of seizure reduction or ketone body production and may be influenced by longer duration of diet therapy. These results support further investigation into specific effects and potential therapeutic benefits on various psychiatric disorders.
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Affiliation(s)
- Abigail Shegelman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Kathryn A Carson
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD 21205, USA; Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Bobbie J Henry-Barron
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Luisa A Diaz-Arias
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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22
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Wiers CE, Vendruscolo LF, van der Veen JW, Manza P, Shokri-Kojori E, Kroll DS, Feldman DE, McPherson KL, Biesecker CL, Zhang R, Herman K, Elvig SK, Vendruscolo JCM, Turner SA, Yang S, Schwandt M, Tomasi D, Cervenka MC, Fink-Jensen A, Benveniste H, Diazgranados N, Wang GJ, Koob GF, Volkow ND. Ketogenic diet reduces alcohol withdrawal symptoms in humans and alcohol intake in rodents. Sci Adv 2021; 7:7/15/eabf6780. [PMID: 33837086 PMCID: PMC8034849 DOI: 10.1126/sciadv.abf6780] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/19/2021] [Indexed: 05/15/2023]
Abstract
Individuals with alcohol use disorder (AUD) show elevated brain metabolism of acetate at the expense of glucose. We hypothesized that a shift in energy substrates during withdrawal may contribute to withdrawal severity and neurotoxicity in AUD and that a ketogenic diet (KD) may mitigate these effects. We found that inpatients with AUD randomized to receive KD (n = 19) required fewer benzodiazepines during the first week of detoxification, in comparison to those receiving a standard American (SA) diet (n = 14). Over a 3-week treatment, KD compared to SA showed lower "wanting" and increased dorsal anterior cingulate cortex (dACC) reactivity to alcohol cues and altered dACC bioenergetics (i.e., elevated ketones and glutamate and lower neuroinflammatory markers). In a rat model of alcohol dependence, a history of KD reduced alcohol consumption. We provide clinical and preclinical evidence for beneficial effects of KD on managing alcohol withdrawal and on reducing alcohol drinking.
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Affiliation(s)
- Corinde E Wiers
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA.
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | | | | | - Peter Manza
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
| | | | - Danielle S Kroll
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
| | - Dana E Feldman
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
| | | | | | - Rui Zhang
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
| | - Kimberly Herman
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
| | - Sophie K Elvig
- National Institute on Drug Abuse, Baltimore, MD 21224, USA
| | | | - Sara A Turner
- Clinical Center Nutrition Department, National Institutes of Health, Bethesda, MD 20892, USA
| | - Shanna Yang
- Clinical Center Nutrition Department, National Institutes of Health, Bethesda, MD 20892, USA
| | - Melanie Schwandt
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
| | - Dardo Tomasi
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
| | | | - Anders Fink-Jensen
- Psychiatric Centre Copenhagen, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Helene Benveniste
- Department of Anesthesiology, Yale University, New Haven, CT 06519, USA
| | - Nancy Diazgranados
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
| | - Gene-Jack Wang
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
| | - George F Koob
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA
- National Institute on Drug Abuse, Baltimore, MD 21224, USA
| | - Nora D Volkow
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD 20892, USA.
- National Institute on Drug Abuse, Baltimore, MD 21224, USA
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23
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Katz JB, Owusu K, Nussbaum I, Beekman R, DeFilippo NA, Gilmore EJ, Hirsch LJ, Cervenka MC, Maciel CB. Pearls and Pitfalls of Introducing Ketogenic Diet in Adult Status Epilepticus: A Practical Guide for the Intensivist. J Clin Med 2021; 10:881. [PMID: 33671485 PMCID: PMC7926931 DOI: 10.3390/jcm10040881] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/04/2021] [Accepted: 02/13/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Status epilepticus (SE) carries an exceedingly high mortality and morbidity, often warranting an aggressive therapeutic approach. Recently, the implementation of a ketogenic diet (KD) in adults with refractory and super-refractory SE has been shown to be feasible and effective. Methods: We describe our experience, including the challenges of achieving and maintaining ketosis, in an adult with new onset refractory status epilepticus (NORSE). Case Vignette: A previously healthy 29-year-old woman was admitted with cryptogenic NORSE following a febrile illness; course was complicated by prolonged super-refractory SE. A comprehensive work-up was notable only for mild cerebral spinal fluid (CSF) pleocytosis, elevated nonspecific serum inflammatory markers, and edematous hippocampi with associated diffusion restriction on magnetic resonance imaging (MRI). Repeat CSF testing was normal and serial MRIs demonstrated resolution of edema and diffusion restriction with progressive hippocampal and diffuse atrophy. She required prolonged therapeutic coma with high anesthetic infusion rates, 16 antiseizure drug (ASD) trials, empiric immunosuppression and partial bilateral oophorectomy. Enteral ketogenic formula was started on hospital day 28. However, sustained beta-hydroxybutyrate levels >2 mmol/L were only achieved 37 days later following a comprehensive adjustment of the care plan. KD was challenging to maintain in the intensive care unit (ICU) and was discontinued due to poor nutritional state and pressure ulcers. KD was restarted again in a non-ICU unit facilitating ASD tapering without re-emergence of SE. Discussion: There are inconspicuous carbohydrates in commonly administered medications for SE including antibiotics, electrolyte repletion formulations, different preparations of the same drug (i.e., parenteral, tablet, or suspension) and even solutions used for oral care-all challenging the use of KD in the hospitalized patient. Tailoring comprehensive care and awareness of possible complications of KD are important for the successful implementation and maintenance of ketosis.
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Affiliation(s)
- Jason B. Katz
- Department of Neurology, Neurocritical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL 32611, USA;
| | - Kent Owusu
- Department of Neurology, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT 06520, USA; (K.O.); (I.N.); (R.B.); (E.J.G.); (L.J.H.)
- Care Signature, Yale New Haven Health, New Haven, CT 06510, USA
| | - Ilisa Nussbaum
- Department of Neurology, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT 06520, USA; (K.O.); (I.N.); (R.B.); (E.J.G.); (L.J.H.)
| | - Rachel Beekman
- Department of Neurology, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT 06520, USA; (K.O.); (I.N.); (R.B.); (E.J.G.); (L.J.H.)
| | - Nicholas A. DeFilippo
- Department of Pharmacy Services, Yale New Haven Hospital, New Haven, CT 06510, USA;
- School of Pharmacy, University of Connecticut, Storrs, CT 06269, USA
| | - Emily J. Gilmore
- Department of Neurology, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT 06520, USA; (K.O.); (I.N.); (R.B.); (E.J.G.); (L.J.H.)
| | - Lawrence J. Hirsch
- Department of Neurology, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT 06520, USA; (K.O.); (I.N.); (R.B.); (E.J.G.); (L.J.H.)
| | - Mackenzie C. Cervenka
- Department of Neurology, Epilepsy Division, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
| | - Carolina B. Maciel
- Department of Neurology, Neurocritical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL 32611, USA;
- Department of Neurology, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT 06520, USA; (K.O.); (I.N.); (R.B.); (E.J.G.); (L.J.H.)
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McDonald TJW, Diaz-Arias L, Vizthum D, Henry-Barron BJ, Schlechter H, Kossoff EH, Cervenka MC. Six-month effects of modified Atkins diet implementation on indices of cardiovascular disease risk in adults with epilepsy. Nutr Neurosci 2021; 25:1548-1557. [PMID: 33487129 DOI: 10.1080/1028415x.2021.1875301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND/AIMS Ketogenic diet therapies (KDTs) offer a needed therapeutic option for patients with drug-resistant epilepsy. The current study investigated biochemical and anthropometric indices of cardiovascular disease (CVD) risk in adults with epilepsy treated with KDT over 6 months. METHOD 65 adults with epilepsy naïve to diet therapy were enrolled in a prospective longitudinal study and instructed on modified Atkins diet (MAD) use. Seizure frequency, anthropometric measures, blood levels of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, apolipoproteins A1 and B, and lipoprotein sub-fractions were assessed at baseline, 3 months, and 6 months. RESULTS Subsequent to study enrollment, 34 participants were lost to follow-up, elected not to start, or stopped MAD prior to study completion, leaving a total of 31 participants in the study at 6 months. Compared to baseline, participants on MAD showed significant reductions in median seizure frequency/week, weight, body mass index, waist and hip circumference, and percent body fat at 3 and 6 months. Compared to baseline, participants on MAD for 3 months showed significantly increased levels of total, small and medium LDL particles, ApoB and ApoB/A1 ratio. At 6 months, only small LDL particles and ApoB levels remained elevated and levels of ApoA1 had risen, suggesting possible compensatory adaptation over time. CONCLUSIONS This study provides evidence demonstrating the efficacy and cardiovascular safety of 6 months of MAD use by adults with epilepsy. It also highlights an index of CVD risk - small LDL particles - that should be closely monitored..Trial registration: ClinicalTrials.gov identifier: NCT02694094..
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Affiliation(s)
- Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Luisa Diaz-Arias
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Diane Vizthum
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, USA
| | - Bobbie J Henry-Barron
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, USA
| | - Haley Schlechter
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, USA
| | - Eric H Kossoff
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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25
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Abstract
Ketogenic diet therapies are high-fat, low-carbohydrate diets designed to mimic a fasting state. Although initially developed nearly one century ago for seizure management, most clinical trials for the management of drug-resistant epilepsy in children as well as adults have been conducted over the last 3 decades. Moreover, ketogenic diets offer promising new adjunctive strategies in the critical care setting for the resolution of acute status epilepticus when traditional antiseizure drugs and anesthetic agents fail. Here, we review the history of ketogenic diet development, the clinical evidence supporting its use for the treatment of drug-resistant epilepsy in children and adults, and the early evidence supporting ketogenic diet feasibility, safety, and potential efficacy in the management of status epilepticus.
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26
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Kossoff EH, Turner Z, Adams J, Bessone SK, Avallone J, McDonald TJ, Diaz-Arias L, Barron BJ, Vizthum D, Cervenka MC. Ketogenic diet therapy provision in the COVID-19 pandemic: Dual-center experience and recommendations. Epilepsy Behav 2020; 111:107181. [PMID: 32512472 PMCID: PMC7247448 DOI: 10.1016/j.yebeh.2020.107181] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 01/08/2023]
Abstract
The current coronavirus-19 pandemic has changed dramatically how neurologists care for children and adults with epilepsy. Stay-at-home orders and resistance to hospitalizations by patients have led epileptologists to engage in telemedicine and reevaluate how to provide elective services. Ketogenic diet therapy is often started in the hospital, with families educated in hospital-based classes, but this is difficult to do in this current pandemic. At our two academic centers, both our pediatric and adult epilepsy diet centers have had to quickly consider alternative methods to both start and maintain ketogenic diet therapy. This paper provides several examples of how ketogenic diet therapy can be provided to patients in unique ways, along with recommendations from other experts and patients, learned over the past few months.
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Affiliation(s)
- Eric H. Kossoff
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, United States of America,Department of Neurology, Johns Hopkins University, Baltimore, MD, United States of America,Corresponding author at: Suite 2158 – 200 North Wolfe Street, Baltimore, MD 21287, United States of America
| | - Zahava Turner
- Division of Nutrition, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, United States of America
| | - Jamie Adams
- Division of Nutrition, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, United States of America
| | - Stacey K. Bessone
- Institute for Brain Protection Sciences, Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States of America
| | - Jennifer Avallone
- Department of Nutritional Services, Johns Hopkins University School of Medicine, United States of America
| | - Tanya J.W. McDonald
- Department of Neurology, Johns Hopkins University, Baltimore, MD, United States of America
| | - Luisa Diaz-Arias
- Department of Neurology, Johns Hopkins University, Baltimore, MD, United States of America
| | - Bobbie J. Barron
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Diane Vizthum
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Mackenzie C. Cervenka
- Department of Neurology, Johns Hopkins University, Baltimore, MD, United States of America
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27
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Simpkins AN, Busl KM, Amorim E, Barnett-Tapia C, Cervenka MC, Dhakar MB, Etherton MR, Fung C, Griggs R, Holloway RG, Kelly AG, Khan IR, Lizarraga KJ, Madagan HG, Onweni CL, Mestre H, Rabinstein AA, Rubinos C, Dionisio-Santos DA, Youn TS, Merck LH, Maciel CB. Proceedings from the Neurotherapeutics Symposium on Neurological Emergencies: Shaping the Future of Neurocritical Care. Neurocrit Care 2020; 33:636-645. [PMID: 32959201 PMCID: PMC7736003 DOI: 10.1007/s12028-020-01085-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/19/2020] [Indexed: 12/11/2022]
Abstract
Effective treatment options for patients with life-threatening neurological disorders are limited. To address this unmet need, high-impact translational research is essential for the advancement and development of novel therapeutic approaches in neurocritical care. "The Neurotherapeutics Symposium 2019-Neurological Emergencies" conference, held in Rochester, New York, in June 2019, was designed to accelerate translation of neurocritical care research via transdisciplinary team science and diversity enhancement. Diversity excellence in the neuroscience workforce brings innovative and creative perspectives, and team science broadens the scientific approach by incorporating views from multiple stakeholders. Both are essential components needed to address complex scientific questions. Under represented minorities and women were involved in the organization of the conference and accounted for 30-40% of speakers, moderators, and attendees. Participants represented a diverse group of stakeholders committed to translational research. Topics discussed at the conference included acute ischemic and hemorrhagic strokes, neurogenic respiratory dysregulation, seizures and status epilepticus, brain telemetry, neuroprognostication, disorders of consciousness, and multimodal monitoring. In these proceedings, we summarize the topics covered at the conference and suggest the groundwork for future high-yield research in neurologic emergencies.
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Affiliation(s)
- Alexis N Simpkins
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Room L3-100, 1149 Newell Drive, Gainesville, FL, 32611, USA.
| | - Katharina M Busl
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Room L3-100, 1149 Newell Drive, Gainesville, FL, 32611, USA
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Carolina Barnett-Tapia
- Ellen and Martin Prosserman Centre for Neuromuscular Disorders, Toronto General Hospital, Toronto, ON, Canada
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Monica B Dhakar
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Mark R Etherton
- J. Phillip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Celia Fung
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Robert Griggs
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Adam G Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Imad R Khan
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Karlo J Lizarraga
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Hannah G Madagan
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Room L3-100, 1149 Newell Drive, Gainesville, FL, 32611, USA
| | - Chidinma L Onweni
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Humberto Mestre
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, USA
| | | | - Clio Rubinos
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Teddy S Youn
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Lisa H Merck
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL, USA
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, FL, USA
| | - Carolina B Maciel
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Room L3-100, 1149 Newell Drive, Gainesville, FL, 32611, USA
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
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Brandt J, Buchholz A, Henry-Barron B, Vizthum D, Avramopoulos D, Cervenka MC. Preliminary Report on the Feasibility and Efficacy of the Modified Atkins Diet for Treatment of Mild Cognitive Impairment and Early Alzheimer's Disease. J Alzheimers Dis 2020; 68:969-981. [PMID: 30856112 DOI: 10.3233/jad-180995] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ketone bodies, the products of fat metabolism, are a source of energy for the brain and are available even when glucose supplies are inadequate (such as with severe carbohydrate deprivation) or its metabolism is faulty (as it is in Alzheimer's disease). This phase I/II randomized clinical trial examined the feasibility of using a modified Atkins diet (MAD) to induce ketogenesis in persons with mild cognitive impairment (MCI) or early AD, and the effect of this diet on memory and other clinical outcomes. In the first 2.5 years of active recruitment, only 27 eligible and willing patients enrolled. After extensive assessment and education, they and their study partners were randomly assigned for 12 weeks to either the MAD or the National Institute on Aging (NIA) recommended diet for seniors. As of April 2018, 9 patients in the MAD arm and 5 in the NIA arm have completed the trial. In spite of extensive teaching, coaching, and monitoring, adherence to both diets was only fair. Among those in the MAD arm who generated at least trace amounts of urinary ketones, there was a large (effect size = 0.53) and statistically significant (p = 0.03) increase in Memory Composite Score between the baseline and week-6 assessment. MAD participants also reported increased energy between baseline and week-6 assessment. Despite challenges to implementing this trial, resulting in a small sample, our preliminary data suggest that the generation of even trace ketones might enhance episodic memory and patient-reported vitality in very early AD.
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Affiliation(s)
- Jason Brandt
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alison Buchholz
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bobbie Henry-Barron
- Institute for Clinical and Translational Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Diane Vizthum
- Institute for Clinical and Translational Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dimitrios Avramopoulos
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Institute of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mackenzie C Cervenka
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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29
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Korzeniewska A, Wang Y, Benz HL, Fifer MS, Collard M, Milsap G, Cervenka MC, Martin A, Gotts SJ, Crone NE. Changes in human brain dynamics during behavioral priming and repetition suppression. Prog Neurobiol 2020; 189:101788. [PMID: 32198060 DOI: 10.1016/j.pneurobio.2020.101788] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 01/13/2020] [Accepted: 03/13/2020] [Indexed: 11/29/2022]
Abstract
Behavioral responses to a perceptual stimulus are typically faster with repeated exposure to the stimulus (behavioral priming). This implicit learning mechanism is critical for survival but impaired in a variety of neurological disorders, including Alzheimer's disease. Many studies of the neural bases for behavioral priming have encountered an interesting paradox: in spite of faster behavioral responses, repeated stimuli usually elicit weaker neural responses (repetition suppression). Several neurophysiological models have been proposed to resolve this paradox, but noninvasive techniques for human studies have had insufficient spatial-temporal precision for testing their predictions. Here, we used the unparalleled precision of electrocorticography (ECoG) to analyze the timing and magnitude of task-related changes in neural activation and propagation while patients named novel vs repeated visual objects. Stimulus repetition was associated with faster verbal responses and decreased neural activation (repetition suppression) in ventral occipito-temporal cortex (VOTC) and left prefrontal cortex (LPFC). Interestingly, we also observed increased neural activation (repetition enhancement) in LPFC and other recording sites. Moreover, with analysis of high gamma propagation we observed increased top-down propagation from LPFC into VOTC, preceding repetition suppression. The latter results indicate that repetition suppression and behavioral priming are associated with strengthening of top-down network influences on perceptual processing, consistent with predictive coding models of repetition suppression, and they support a central role for changes in large-scale cortical dynamics in achieving more efficient and rapid behavioral responses.
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Affiliation(s)
- Anna Korzeniewska
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, 21287, USA.
| | - Yujing Wang
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, 21287, USA
| | - Heather L Benz
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, 21287, USA
| | - Matthew S Fifer
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, 21287, USA
| | - Max Collard
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, 21287, USA
| | - Griffin Milsap
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, 21287, USA
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, 21287, USA
| | - Alex Martin
- Laboratory of Brain and Cognition, National Institute of Mental Health, Bethesda, Maryland, 20852, USA
| | - Stephen J Gotts
- Laboratory of Brain and Cognition, National Institute of Mental Health, Bethesda, Maryland, 20852, USA
| | - Nathan E Crone
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, 21287, USA
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Abstract
The use of ketogenic diet therapies (KDT) in adults has expanded in the last two decades and has been accompanied by a surge of new retrospective as well as prospective studies evaluating its efficacy in adults with epilepsy. In this review article, we will highlight the recent clinical trials and advances in the use of the ketogenic diet therapy (KDT) in adult patients with epilepsy. We will analyze the responder rate in regard to the epilepsy syndrome (focal vs generalized) to identify adults who are optimal to consider for KDT. In addition to its role in treating patients with chronic epilepsy, we will explore the emerging use of the KDT in the critical care setting in adults with refractory and super-refractory status epilepticus as well as other neurologic disorders. Finally, we will discuss special considerations for the use of KDT in adults with epilepsy including its potential long-term effects on bone and cardiovascular health, and its use in pregnancy.
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Affiliation(s)
- Khalil S Husari
- Comprehensive Epilepsy Center, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Mackenzie C Cervenka
- Comprehensive Epilepsy Center, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.
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31
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Gugger JJ, Husari K, Probasco JC, Cervenka MC. New-onset refractory status epilepticus: A retrospective cohort study. Seizure 2019; 74:41-48. [PMID: 31830676 DOI: 10.1016/j.seizure.2019.12.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To describe the clinical, laboratory, neuroimaging, electroencephalographic features, etiology, treatment, as well as short-term and long-term outcomes of adults with new-onset refractory status epilepticus (NORSE). METHOD A retrospective, single institution cohort study (2010-2018) of consecutive adult patients with NORSE. RESULTS Among 20 patients with NORSE, nine (45 %) had prodromal febrile illness, 12 (60 %) had evidence of inflammation on CSF profile. Six patients (30 %) met criteria for definite autoimmune encephalitis (AE) while 8 patients (40 %) had probable AE. Eleven out of 13 (85 %) patients had an abnormal FDG-PET scan with the most common finding being regional hypermetabolism. Fourteen patients (70 %) received immunotherapy and ten (50 %) received the ketogenic diet (KD). Fifteen patients (75 %) progressed to super-refractory status epilepticus (SRSE) and seven patients (35 %) died in the hospital or within six months of discharge. Among the surviving patients, eight (40 %) had a good outcome (i.e., modified Rankin Scale score 0-2); 12 (80 %) received a diagnosis of epilepsy of which nine (75 %) developed drug-resistant epilepsy. CONCLUSIONS New-onset refractory status epilepticus is a syndrome associated with multiple complications, high mortality, and subsequent intractable epilepsy. There are multiple causes, some of which are autoimmune encephalitides; however, in this series the majority of patients had no clear etiology identified after extensive evaluation. Prospective studies are needed to determine optimal evaluation and treatment.
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Affiliation(s)
- James J Gugger
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Department of Neurology, 600 N. Wolfe St, Baltimore, MD, 21287-7247, USA.
| | - Khalil Husari
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Department of Neurology, 600 N. Wolfe St, Baltimore, MD, 21287-7247, USA
| | - John C Probasco
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Department of Neurology, 600 N. Wolfe St, Baltimore, MD, 21287-7247, USA
| | - Mackenzie C Cervenka
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Department of Neurology, 600 N. Wolfe St, Baltimore, MD, 21287-7247, USA
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Abstract
PURPOSE OF REVIEW Although ketogenic diet therapies (KDTs) were first developed as a treatment for patients with epilepsy, their potential efficacy for a broader number of neurologic and nonneurologic disorders and conditions has been explored over the last 10-20 years. The most recent clinical trials of KDTs in adults have highlighted common methodological aspects that can either facilitate or thwart appropriate risk/benefit analyses, comparisons across studies, and reproducibility of findings in future studies. RECENT FINDINGS Recent evidence suggests that KDTs not only improve seizure control, but also improve other neurologic conditions, including nonmotor Parkinson's disease symptoms. Therapies targeting nutritional ketosis without comprehensive diet modification improve cognition and cerebral blood flow in Alzheimer's disease patients. KDTs lower hemoglobin A1c levels and diabetes medication use in patients with Type 2 diabetes and mixed results have been observed when used for performance enhancement in athletes and healthy volunteers. SUMMARY Clinical studies of KDTs show promise for a variety of clinical indications. Future studies should factor in high potential participant attrition rates and utilize consistent and standard reporting of diet type(s), compliance measures, and side-effects to enable the reproducibility and generalizability of study outcomes.
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Affiliation(s)
- Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
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33
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Berrington A, Schreck KC, Barron BJ, Blair L, Lin DDM, Hartman AL, Kossoff E, Easter L, Whitlow CT, Jung Y, Hsu FC, Cervenka MC, Blakeley JO, Barker PB, Strowd RE. Cerebral Ketones Detected by 3T MR Spectroscopy in Patients with High-Grade Glioma on an Atkins-Based Diet. AJNR Am J Neuroradiol 2019; 40:1908-1915. [PMID: 31649157 DOI: 10.3174/ajnr.a6287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/04/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Ketogenic diets are being explored as a possible treatment for several neurological diseases, but the physiologic impact on the brain is unknown. The objective of this study was to evaluate the feasibility of 3T MR spectroscopy to monitor brain ketone levels in patients with high-grade gliomas who were on a ketogenic diet (a modified Atkins diet) for 8 weeks. MATERIALS AND METHODS Paired pre- and post-ketogenic diet MR spectroscopy data from both the lesion and contralateral hemisphere were analyzed using LCModel software in 10 patients. RESULTS At baseline, the ketone bodies acetone and β-hydroxybutyrate were nearly undetectable, but by week 8, they increased in the lesion for both acetone (0.06 ± 0.03 ≥ 0.27 ± 0.06 IU, P = .005) and β-hydroxybutyrate (0.07 ± 0.07 ≥ 0.79 ± 0.32 IU, P = .046). In the contralateral brain, acetone was also significantly increased (0.041 ± 0.01 ≥ 0.16 ± 0.04 IU, P = .004), but not β-hydroxybutyrate. Acetone was detected in 9/10 patients at week 8, and β-hydroxybutyrate, in 5/10. Acetone concentrations in the contralateral brain correlated strongly with higher urine ketones (r = 0.87, P = .001) and lower fasting glucose (r = -0.67, P = .03). Acetoacetate was largely undetectable. Small-but-statistically significant decreases in NAA were also observed in the contralateral hemisphere at 8 weeks. CONCLUSIONS This study suggests that 3T MR spectroscopy is feasible for detecting small cerebral metabolic changes associated with a ketogenic diet, provided that appropriate methodology is used.
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Affiliation(s)
- A Berrington
- From the Russell H. Morgan Departments of Radiology and Radiological Science (A.B., D.D.M.L., P.B.B.)
| | - K C Schreck
- Neurology (K.C.S., L.B., A.L.H., E.K., M.C.C., J.O.B., R.E.S.)
| | - B J Barron
- Institute of Clinical and Translational Research (B.J.B.), Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - L Blair
- Neurology (K.C.S., L.B., A.L.H., E.K., M.C.C., J.O.B., R.E.S.).,Pediatrics (L.B., A.L.H.)
| | - D D M Lin
- From the Russell H. Morgan Departments of Radiology and Radiological Science (A.B., D.D.M.L., P.B.B.)
| | - A L Hartman
- Neurology (K.C.S., L.B., A.L.H., E.K., M.C.C., J.O.B., R.E.S.).,Pediatrics (L.B., A.L.H.)
| | - E Kossoff
- Neurology (K.C.S., L.B., A.L.H., E.K., M.C.C., J.O.B., R.E.S.)
| | - L Easter
- Clinical and Translational Science Institute (L.E., R.E.S.)
| | | | - Y Jung
- Departments of Radiology (C.T.W., Y.J.)
| | - F-C Hsu
- Biostatistics and Data Science (F.-C.H.), Division of Public Health Sciences
| | - M C Cervenka
- Neurology (K.C.S., L.B., A.L.H., E.K., M.C.C., J.O.B., R.E.S.)
| | - J O Blakeley
- Neurology (K.C.S., L.B., A.L.H., E.K., M.C.C., J.O.B., R.E.S.)
| | - P B Barker
- From the Russell H. Morgan Departments of Radiology and Radiological Science (A.B., D.D.M.L., P.B.B.) .,F. M. Kirby Research Center for Functional Brain Imaging (P.B.B., R.E.S.), Kennedy Krieger Institute, Baltimore, Maryland
| | - R E Strowd
- Neurology (K.C.S., L.B., A.L.H., E.K., M.C.C., J.O.B., R.E.S.).,Clinical and Translational Science Institute (L.E., R.E.S.).,Departments of Neurology, Hematology and Oncology (R.E.S.), Wake Forest School of Medicine, Winston-Salem, North Carolina.,F. M. Kirby Research Center for Functional Brain Imaging (P.B.B., R.E.S.), Kennedy Krieger Institute, Baltimore, Maryland
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Di Lorenzo C, Coppola G, Bracaglia M, Di Lenola D, Sirianni G, Rossi P, Di Lorenzo G, Parisi V, Serrao M, Cervenka MC, Pierelli F. A ketogenic diet normalizes interictal cortical but not subcortical responsivity in migraineurs. BMC Neurol 2019; 19:136. [PMID: 31228957 PMCID: PMC6588932 DOI: 10.1186/s12883-019-1351-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/31/2019] [Indexed: 11/26/2022] Open
Abstract
Background A short ketogenic diet (KD) treatment can prevent migraine attacks and correct excessive cortical response. Here, we aim to prove if the KD-related changes of cortical excitability are primarily due to cerebral cortex activity or are modulated by the brainstem. Methods Through the stimulation of the right supraorbital division of the trigeminal nerve, we concurrently interictally recorded the nociceptive blink reflex (nBR) and the pain-related evoked potentials (PREP) in 18 migraineurs patients without aura before and after 1-month on KD, while in metabolic ketosis. nBR and PREP reflect distinct brain structures activation: the brainstem and the cerebral cortex respectively. We estimated nBR R2 component area-under-the-curve as well as PREP amplitude habituation as the slope pof the linear regression between the 1st and the 2nd block of 5 averaged responses. Results Following 1-month on KD, the mean number of attacks and headache duration reduced significantly. Moreover, KD significantly normalized the interictal PREP habituation (pre: + 1.8, post: − 9.1, p = 0.012), while nBR deficit of habituation did not change. Conclusions The positive clinical effects we observed in a population of migraineurs by a 1-month KD treatment coexists with a normalization at the cortical level, not in the brainstem, of the typical interictal deficit of habituation. These findings suggest that the cerebral cortex may be the primary site of KD-related modulation. Trial registration ClinicalTrials.gov NCT03775252 (retrospectively registered, December 09, 2018).
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Affiliation(s)
| | - Gianluca Coppola
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University Rof Rome Polo Pontino, Latina, Italy
| | - Martina Bracaglia
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University Rof Rome Polo Pontino, Latina, Italy
| | - Davide Di Lenola
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University Rof Rome Polo Pontino, Latina, Italy
| | | | - Paolo Rossi
- INI, Headache Clinic, Grottaferrata (RM), Italy
| | - Giorgio Di Lorenzo
- Laboratory of Psychophysiology, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Vincenzo Parisi
- Research Unit of Neurophysiology of Vision and Neurophthalmology, IRCCS - Fondazione Bietti, Rome, Italy
| | - Mariano Serrao
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University Rof Rome Polo Pontino, Latina, Italy
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Francesco Pierelli
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University Rof Rome Polo Pontino, Latina, Italy.,IRCCS - Neuromed, Pozzilli, IS, Italy
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Babajani-Feremi A, Wheless JW, Papanicolaou JW, Wang Y, Fifer MS, Flinker A, Korzeniewska A, Cervenka MC, Anderson WS, Boatman-Reich DF, Crone NE. Spatial-temporal functional mapping of language at the bedside with electrocorticography. Neurology 2019; 87:2604. [PMID: 27956570 DOI: 10.1212/01.wnl.0000511287.40052.8d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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36
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Freund B, Probasco JC, Cervenka MC, Sutter R, Kaplan PW. EEG Differences in Two Clinically Similar Rapid Dementias: Voltage-Gated Potassium Channel Complex-Associated Autoimmune Encephalitis and Creutzfeldt-Jakob Disease. Clin EEG Neurosci 2019; 50:121-128. [PMID: 29788790 DOI: 10.1177/1550059418774686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Distinguishing treatable causes for rapidly progressive dementia from those that are incurable is vital. Creutzfeldt-Jakob disease (CJD) and voltage-gated potassium channel complex-associated autoimmune encephalitis (VGKC AE) are 2 such conditions with disparate outcomes and response to treatment. To determine the differences in electroencephalography between CJD and VGKC AE, we performed a retrospective review of medical records and examined clinical data, neuroimaging, and electroencephalographs performed in patients admitted for evaluation for rapidly progressive dementia diagnosed with CJD and VGKC AE at the Johns Hopkins Hospital and Bayview Medical Center between January 1, 2007 and December 31, 2015. More patients in the VGKC AE group had seizures (12/17) than those with CJD (3/14; P = .008). Serum sodium levels were lower in those with VGKC AE (P = .001). Cerebrospinal fluid (CSF) white blood cell count was higher in VGKC AE (P = .008). CSF protein 14-3-3 (P = .018) was more commonly detected in CJD, and tau levels were higher in those with CJD (P < .006). On neuroimaging, diffusion restriction in the cortex (P = .001), caudate (P < .001), and putamen (P = .001) was more frequent in CJD. Periodic sharp wave complexes (P = .001) and generalized suppressed activity (P = .008) were more common on initial EEG in CJD. On serial EEGs, generalized periodic discharges (P = .004), generalized suppressed activity (P=0.008), and periodic sharp wave complexes (P < .001) were detected more in CJD. This study shows that there are a number of differentiating features between CJD and VGKC AE, and electroencephalography can aid in their diagnoses. Performing serial EEGs better delineates these conditions.
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Affiliation(s)
- Brin Freund
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - John C Probasco
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Raoul Sutter
- Department of Neurology and Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Abstract
The goal of this study was to determine the value of a certified child life specialist (CCLS) on the patient and staff experiences in an epilepsy monitoring unit (EMU). We integrated a CCLS into the EMU for all children as well as adults with intellectual disability. We surveyed families to determine the impact of child life services on their stay. EMU staff completed questionnaires to determine perceived impact to their job performance from the integration of the CCLS. All of the families (pediatric and adult patients) who responded to the survey reported the presence of the CCLS improved their hospital experience. Staff reported that the CCLS improved their daily work by allowing them to focus on their assigned medical duties. This preliminary pilot study suggests that CCLS can have a strong impact on the experience of patients and staff in an EMU.
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Abstract
The current review highlights the evidence supporting the use of ketogenic diet therapies in the management of a growing number of neurological disorders in adults. An overview of the scientific literature supporting posited mechanisms of therapeutic efficacy is presented including effects on neurotransmission, oxidative stress, and neuro-inflammation. The clinical evidence supporting ketogenic diet use in the management of adult epilepsy, malignant glioma, Alzheimer's disease, migraine headache, motor neuron disease, and other neurologic disorders is highlighted and reviewed. Lastly, common adverse effects of ketogenic therapy in adults, including gastrointestinal symptoms, weight loss, and transient dyslipidemia are discussed.
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Affiliation(s)
- Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, Maryland, 21287, USA
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, Maryland, 21287, USA.
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McDonald TJW, Cervenka MC. The Expanding Role of Ketogenic Diets in Adult Neurological Disorders. Brain Sci 2018; 8:E148. [PMID: 30096755 PMCID: PMC6119973 DOI: 10.3390/brainsci8080148] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 12/15/2022] Open
Abstract
The current review highlights the evidence supporting the use of ketogenic diet therapies in the management of adult epilepsy, adult malignant glioma and Alzheimer's disease. An overview of the scientific literature, both preclinical and clinical, in each area is presented and management strategies for addressing adverse effects and compliance are discussed.
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Affiliation(s)
- Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD 21287, USA.
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD 21287, USA.
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McDonald TJW, Henry-Barron BJ, Felton EA, Gutierrez EG, Barnett J, Fisher R, Lwin M, Jan A, Vizthum D, Kossoff EH, Cervenka MC. Improving compliance in adults with epilepsy on a modified Atkins diet: A randomized trial. Seizure 2018; 60:132-138. [PMID: 29960852 DOI: 10.1016/j.seizure.2018.06.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/16/2018] [Accepted: 06/22/2018] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To determine whether use of a ketogenic formula during the first month of the modified Atkins diet (MAD) in adults with drug-resistant epilepsy (DRE) improves seizure reduction and compliance compared to MAD alone. METHODS Eighty adults (age ≥18 years) with DRE and ≥4 reliably quantifiable seizures/month were enrolled. All participants were trained to follow a 20 g/day net carbohydrate limit MAD. Patients were randomized to receive one 8-ounce (237 mL) tetrapak of KetoCal®, a 4:1 ketogenic ratio formula, daily in combination with MAD during the first month (treatment arm) or second month (control/cross-over arm). Patients recorded urine ketones, weight, and seizure frequency and followed up at 1 and 2 months. RESULTS By 1 month, 84% of patients achieved ketosis (median of 4-4.5 days). At 1 month, the treatment arm had a significantly higher ketogenic ratio and more patients with a ≥1:1 ketogenic ratio compared to the control arm. There was no difference in median seizure frequency, proportion of responders (≥50% seizure reduction), or median seizure reduction from baseline between groups. However, patients treated with KetoCal® during the first month were significantly more likely to continue MAD for 6 months or more. CONCLUSION Although supplementing MAD with a ketogenic formula in the first month did not increase the likelihood of reducing seizures compared to MAD alone, significantly more adults remained on MAD long-term with this approach. This suggests a potential strategy for encouraging compliance with MAD in adults with DRE.
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Affiliation(s)
- Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Bobbie J Henry-Barron
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, United States.
| | - Elizabeth A Felton
- Department of Neurology, University of Wisconsin, Madison, WI, United States.
| | - Erie G Gutierrez
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Joanne Barnett
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Rebecca Fisher
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - MonYi Lwin
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Amanda Jan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Diane Vizthum
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, United States.
| | - Eric H Kossoff
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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McDonald TJW, Ratchford EV, Henry-Barron BJ, Kossoff EH, Cervenka MC. Impact of the modified Atkins diet on cardiovascular health in adults with epilepsy. Epilepsy Behav 2018; 79:82-86. [PMID: 29253679 DOI: 10.1016/j.yebeh.2017.10.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/24/2017] [Accepted: 10/27/2017] [Indexed: 11/16/2022]
Abstract
AIM The current study investigated biochemical and vascular markers of cardiovascular health in adult patients with epilepsy treated with long-term (greater than 1year) ketogenic diet therapy compared with controls. METHOD Anthropometric measures, serum fasting lipid panel, apolipoproteins A-1 and B, lipoprotein sub-fractions as well as common carotid intima-media thickness (cIMT), and plaque presence were assessed in 20 adult patients with epilepsy on a modified Atkins diet (MAD) for >1year started as an adult compared with 21 adult patients with epilepsy naïve to diet therapy. RESULTS Patients treated with MAD had significantly lower weight, body mass index, waist and hip circumference, percent body fat, and serum triglyceride levels when compared with control patients. In contrast, they had significantly higher serum levels of small low-density-lipoprotein (LDL) particles and were significantly more likely to have LDL pattern B in which small LDL particles predominate when compared with controls. However, there was no significant difference in cIMT or plaque presence between groups. CONCLUSION Our results provide clinical evidence demonstrating the cardiovascular safety of a high-fat, low-carbohydrate diet used in adults with epilepsy for at least 12months. It also highlights potential markers of cardiovascular risk - small dense LDL particles - that should be closely monitored in adults treated with diet therapy long-term.
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Affiliation(s)
- Tanya J W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Elizabeth V Ratchford
- Johns Hopkins Center for Vascular Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Bobbie J Henry-Barron
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD, United States.
| | - Eric H Kossoff
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Schreck KC, Lwin M, Strowd RE, Henry-Barron BJ, Blakeley JO, Cervenka MC. Effect of ketogenic diets on leukocyte counts in patients with epilepsy. Nutr Neurosci 2017; 22:522-527. [DOI: 10.1080/1028415x.2017.1416740] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Karisa C. Schreck
- Department of Neurology, Johns Hopkins University School of Medicine, Suite1M16, 1550 Orleans Street, Baltimore, MD 21287, USA
| | - MonYi Lwin
- Johns Hopkins University, Suite1M16, 1550 Orleans Street, Baltimore, MD 21287, USA
| | - Roy E. Strowd
- Departments of Neurology and Oncology, Wake Forest School of Medicine, Winston Salem, NC 27157, USA
| | - Bobbie J. Henry-Barron
- Institute for Clinical and Translational Research, Johns Hopkins Medicine, Suite1M16, 1550 Orleans Street, Baltimore, MD 21287, USA
| | - Jaishri O. Blakeley
- Departments of Neurology, Oncology, and Neurosurgery, 1550 Orleans Street, Suite IM16, Baltimore, MD 21287, USA
| | - Mackenzie C. Cervenka
- Department of Neurology, Carnegie 214B, 1800 Orleans Street, Baltimore, MD 21287, USA
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Schreck KC, Berrington A, Barron BM, Blair L, Hartman A, Kossoff E, Easter L, Whitlow C, Hsu FC, Cervenka MC, Blakeley JO, Barker PB, Strowd RE. NIMG-94. FEASIBILITY OF PROTON MRS FOR ASSESSING CEREBRAL METABOLIC ACTIVITY OF AN ATKINS-BASED DIET IN PATIENTS WITH GLIOMA. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Williams TJ, Cervenka MC. The role for ketogenic diets in epilepsy and status epilepticus in adults. Clin Neurophysiol Pract 2017; 2:154-160. [PMID: 30214989 PMCID: PMC6123874 DOI: 10.1016/j.cnp.2017.06.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/19/2017] [Accepted: 06/02/2017] [Indexed: 01/01/2023] Open
Abstract
Ketogenic diets offer adjunctive therapy for chronic epilepsy and refractory status epilepticus. Studies support feasibility and efficacy of the classic ketogenic diet and its variants in adults. Potential complications and side effects of diet therapy are often preventable and manageable. Strategies are needed to improve diet adherence.
Ketogenic diet (KD) therapies are high fat, low carbohydrate diets designed to mimic a fasting state. Although studies demonstrate KD’s success in reducing seizures stretching back nearly a century, the last 25 years have seen a resurgence in diet therapy for the management of drug-resistant epilepsy in children as well as adults. With ≥50% seizure reduction efficacy rates in adults of 22–55% for the classic KD and 12–67% for the modified Atkins diet, diet therapy may be in many instances comparable to a trial of an additional anti-epileptic medication and potentially with fewer side effects and other health benefits. Moreover, ketogenic diets offer promising new adjunctive strategies for the treatment of acute status epilepticus in the intensive care setting. Here, we review the efficacy and utility of ketogenic diets for the management of chronic epilepsy and refractory status epilepticus in adults and offer practical guidelines for diet implementation and maintenance.
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Affiliation(s)
- Tanya J Williams
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD, USA
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD, USA
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von Spiczak S, Helbig KL, Shinde DN, Huether R, Pendziwiat M, Lourenço C, Nunes ME, Sarco DP, Kaplan RA, Dlugos DJ, Kirsch H, Slavotinek A, Cilio MR, Cervenka MC, Cohen JS, McClellan R, Fatemi A, Yuen A, Sagawa Y, Littlejohn R, McLean SD, Hernandez-Hernandez L, Maher B, Møller RS, Palmer E, Lawson JA, Campbell CA, Joshi CN, Kolbe DL, Hollingsworth G, Neubauer BA, Muhle H, Stephani U, Scheffer IE, Pena SDJ, Sisodiya SM, Helbig I. DNM1 encephalopathy: A new disease of vesicle fission. Neurology 2017; 89:385-394. [PMID: 28667181 PMCID: PMC5574673 DOI: 10.1212/wnl.0000000000004152] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/26/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the phenotypic spectrum caused by mutations in dynamin 1 (DNM1), encoding the presynaptic protein DNM1, and to investigate possible genotype-phenotype correlations and predicted functional consequences based on structural modeling. METHODS We reviewed phenotypic data of 21 patients (7 previously published) with DNM1 mutations. We compared mutation data to known functional data and undertook biomolecular modeling to assess the effect of the mutations on protein function. RESULTS We identified 19 patients with de novo mutations in DNM1 and a sibling pair who had an inherited mutation from a mosaic parent. Seven patients (33.3%) carried the recurrent p.Arg237Trp mutation. A common phenotype emerged that included severe to profound intellectual disability and muscular hypotonia in all patients and an epilepsy characterized by infantile spasms in 16 of 21 patients, frequently evolving into Lennox-Gastaut syndrome. Two patients had profound global developmental delay without seizures. In addition, we describe a single patient with normal development before the onset of a catastrophic epilepsy, consistent with febrile infection-related epilepsy syndrome at 4 years. All mutations cluster within the GTPase or middle domains, and structural modeling and existing functional data suggest a dominant-negative effect on DMN1 function. CONCLUSIONS The phenotypic spectrum of DNM1-related encephalopathy is relatively homogeneous, in contrast to many other genetic epilepsies. Up to one-third of patients carry the recurrent p.Arg237Trp variant, which is now one of the most common recurrent variants in epileptic encephalopathies identified to date. Given the predicted dominant-negative mechanism of this mutation, this variant presents a prime target for therapeutic intervention.
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Affiliation(s)
| | | | | | - Robert Huether
- Author affiliations are provided at the end of the article
| | | | | | - Mark E Nunes
- Author affiliations are provided at the end of the article
| | - Dean P Sarco
- Author affiliations are provided at the end of the article
| | | | | | - Heidi Kirsch
- Author affiliations are provided at the end of the article
| | | | - Maria R Cilio
- Author affiliations are provided at the end of the article
| | | | - Julie S Cohen
- Author affiliations are provided at the end of the article
| | | | - Ali Fatemi
- Author affiliations are provided at the end of the article
| | - Amy Yuen
- Author affiliations are provided at the end of the article
| | - Yoshimi Sagawa
- Author affiliations are provided at the end of the article
| | | | - Scott D McLean
- Author affiliations are provided at the end of the article
| | | | - Bridget Maher
- Author affiliations are provided at the end of the article
| | - Rikke S Møller
- Author affiliations are provided at the end of the article
| | | | - John A Lawson
- Author affiliations are provided at the end of the article
| | | | | | - Diana L Kolbe
- Author affiliations are provided at the end of the article
| | | | | | - Hiltrud Muhle
- Author affiliations are provided at the end of the article
| | | | | | | | | | - Ingo Helbig
- Author affiliations are provided at the end of the article.
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Cervenka MC, Hocker S, Koenig M, Bar B, Henry-Barron B, Kossoff EH, Hartman AL, Probasco JC, Benavides DR, Venkatesan A, Hagen EC, Dittrich D, Stern T, Radzik B, Depew M, Caserta FM, Nyquist P, Kaplan PW, Geocadin RG. Phase I/II multicenter ketogenic diet study for adult superrefractory status epilepticus. Neurology 2017; 88:938-943. [PMID: 28179470 DOI: 10.1212/wnl.0000000000003690] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/09/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the feasibility, safety, and efficacy of a ketogenic diet (KD) for superrefractory status epilepticus (SRSE) in adults. METHODS We performed a prospective multicenter study of patients 18 to 80 years of age with SRSE treated with a KD treatment algorithm. The primary outcome measure was significant urine and serum ketone body production as a biomarker of feasibility. Secondary measures included resolution of SRSE, disposition at discharge, KD-related side effects, and long-term outcomes. RESULTS Twenty-four adults were screened for participation at 5 medical centers, and 15 were enrolled and treated with a classic KD via gastrostomy tube for SRSE. Median age was 47 years (interquartile range [IQR] 30 years), and 5 (33%) were male. Median number of antiseizure drugs used before KD was 8 (IQR 7), and median duration of SRSE before KD initiation was 10 days (IQR 7 days). KD treatment delays resulted from intravenous propofol use, ileus, and initial care received at a nonparticipating center. All patients achieved ketosis in a median of 2 days (IQR 1 day) on KD. Fourteen patients completed KD treatment, and SRSE resolved in 11 (79%; 73% of all patients enrolled). Side effects included metabolic acidosis, hyperlipidemia, constipation, hypoglycemia, hyponatremia, and weight loss. Five patients (33%) ultimately died. CONCLUSIONS KD is feasible in adults with SRSE and may be safe and effective. Comparative safety and efficacy must be established with randomized placebo-controlled trials. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that in adults with SRSE, a KD is effective in inducing ketosis.
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Affiliation(s)
- Mackenzie C Cervenka
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD.
| | - Sara Hocker
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Matthew Koenig
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Barak Bar
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Bobbie Henry-Barron
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Eric H Kossoff
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Adam L Hartman
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - John C Probasco
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - David R Benavides
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Arun Venkatesan
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Eliza C Hagen
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Denise Dittrich
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Tracy Stern
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Batya Radzik
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Marie Depew
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Filissa M Caserta
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Paul Nyquist
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Peter W Kaplan
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Romergryko G Geocadin
- From the Departments of Neurology (M.C.C., E.H.K., A.L.H., J.C.P., D.R.B., A.V., B.R., M.D., F.M.C., P.N.), Pediatrics (E.H.K., A.L.H.), and Anesthesiology-Critical Care Medicine (R.G.G.), Neurosurgery and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (S.H.), Mayo Clinic, Rochester, MN; Neuroscience Institute (M.K., E.C.H., D.D., T.S.), Queen's Medical Center, Honolulu, HI; Department of Neurology (B.B.), Loyola University Health System, Maywood, IL; Institute for Clinical and Translational Research (B.H.-B.), Johns Hopkins University, Baltimore, MD; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
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van der Louw EJ, Williams TJ, Henry-Barron BJ, Olieman JF, Duvekot JJ, Vermeulen MJ, Bannink N, Williams M, Neuteboom RF, Kossoff EH, Catsman-Berrevoets CE, Cervenka MC. Ketogenic diet therapy for epilepsy during pregnancy: A case series. Seizure 2017; 45:198-201. [DOI: 10.1016/j.seizure.2016.12.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022] Open
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Cervenka MC, Henry-Barron BJ, Kossoff EH. Is there a role for diet monotherapy in adult epilepsy? Epilepsy Behav Case Rep 2016; 7:6-9. [PMID: 28053859 PMCID: PMC5198064 DOI: 10.1016/j.ebcr.2016.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/09/2016] [Indexed: 06/06/2023]
Abstract
Ten adults were treated with ketogenic diet monotherapy for epilepsy. Four patients were naïve to antiseizure drugs (ASDs), and six previously tried and stopped ASDs. Of four treatment-naïve participants, two (50%) were free from disabling seizures on Modified Atkins Diet (MAD) monotherapy for > 1 year. Two (50%) stopped. Four of six patients (67%) who had previously tried ASDs became seizure-free on diet monotherapy, and two experienced > 50% seizure reduction. Side effects included amenorrhea, weight loss, osteoporosis, and hyperlipidemia. Diet monotherapy may be feasible, well-tolerated, and effective for adults with epilepsy who refuse pharmacotherapy and those for whom lifelong diet therapy is recommended.
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Affiliation(s)
- Mackenzie C. Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD 21287, USA
| | - Bobbie J. Henry-Barron
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Eric H. Kossoff
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD 21287, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, 200 North Wolfe Street, Suite 2158, Baltimore, MD 21287, USA
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Abstract
The accurate diagnosis and classification of seizures is critical in informing prognosis and determining appropriate antiseizure treatments for patients with epilepsy. The electroencephalogram is the gold standard for diagnosis. Obtaining a thorough history, performing a careful physical examination, and selecting appropriate diagnostic studies are also essential in determining the underlying seizure etiology. The authors provide clinical pearls and pitfalls in the diagnosis and management of epilepsy.
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Affiliation(s)
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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Kossoff EH, Doerrer SC, Winesett SP, Turner Z, Henry BJ, Bessone S, Stanfield A, Cervenka MC. Diet Redux: Outcomes from Reattempting Dietary Therapy for Epilepsy. J Child Neurol 2016; 31:1052-6. [PMID: 26961268 DOI: 10.1177/0883073816636225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 08/26/2015] [Indexed: 11/17/2022]
Abstract
The outcome for patients attempting dietary therapy for epilepsy a second time is unknown. Twenty-six subjects treated with the ketogenic diet as children who then began either the ketogenic diet or a Modified Atkins Diet (MAD) at least 6 months later were evaluated. The mean age at the first diet trial was 5.6 years and at the second diet trial was 11.5 years. Most restarted dietary therapy because of persistent seizures (65%) or recurrence after seizure freedom (19%). Overall, 77% had a ≥50% seizure reduction with the first diet, and 50% with the second diet, P = .04. Individual subject responses were largely similar, with 14 (54%) having identical seizure reduction both times, 9 worse (35%) with the second attempt, and 3 (16%) improved. The second diet trial was more likely to lead to >50% seizure reduction if the first trial was started at a later age (7.4 vs 3.9 years, P = .04).
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