Purpose: Epilepsy monitoring unit (EMU) admissions provide a definitive diagnosis for approximately three-quarters of patients. However, many patients do not receive a definitive diagnosis following EMU admission. Ambulatory EEG following nondiagnostic EMU admissions was evaluated as a means of providing a diagnosis for these patients. Methods: In this retrospective study, we performed a chart review of 62 pediatric and adult patients who had a 72-hour ambulatory EEG following a nondiagnostic EMU admission. Results: In total, there were 62 patients with nondiagnostic EMU admissions who subsequently underwent ambulatory EEG. Mean age was 33.8 (SD, 18.5) years. Forty-one patients (66.2%) were female and 46 (74.2%) adult. Fifty patients (80.7%) had an additional comorbid neurologic, somatoform, or psychiatric diagnoses. Of the original 62 patients, 32 (51.6%) had no events, 3 (4.8%) had events with and without EEG changes, 4 (6.5%) had only events with EEG changes, and 23 (37.1%) had only events without EEG changes. Ambulatory EEG thus provided clinically useful information in 30 (48.4%) cases, with 20 (66.7%) reaching diagnosis within 24 hours. Conclusions: Ambulatory EEG following a nondiagnostic EMU admission may yield positive results in approximately half of all patients. A substantial proportion of the events that were captured in this setting were without EEG changes. In the absence of video and supportive clinical information, these events not only may represent nonepileptic events but also could represent focal seizures without EEG changes. The presence of particular stressors in the home environment may explain why many patients, specifically those who are nonepileptic, had events relatively quickly following discharge.

Thoracic outlet syndrome (TOS), a rare condition, results from the compression of neurovascular structures traversing from the neck through the thoracic outlet into the axilla. It can develop from chronic repetitive activities of the upper extremities, commonly reported in athletes playing sports involving vigorous use of arms and shoulders. While symptoms of neurovascular compression can occur, stroke due to TOS in children is not commonly reported. We describe a rare case of a healthy 14-year-old boy, a competitive violinist, with acute limb ischemia from extensive occlusive thrombi involving several arteries in the right upper extremity as well as the right vertebral artery, which ultimately caused infarcts in the bilateral posterior circulation. The etiology was determined to be TOS leading to impingement of the right subclavian artery by a fused cervical rib aggravated by patient's prolonged violin practice. This case represents the first description of stroke from TOS in an adolescent violinist.

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