Rohit R. Das

The Utility of Conductive Plastic Electrodes in Prolonged ICU EEG Monitoring

We investigated the feasibility and utilization of conductive plastic electrodes (CPEs) in patients undergoing continuous video-electroencephalographic (EEG) monitoring in the intensive care unit (ICU), and assessed the quality of brain magnetic resonance imaging (MRI) and computed tomography (CT) images obtained during this period. A total of 54 patients were monitored. Seizures were recorded in 16 patients. Twenty-five patients had neuroimaging performed with electrodes in place; 15 MRI and 23 CT scans were performed. All patients had excellent quality anatomical images without clinically significant artifacts, and without any signs or symptoms that raised safety concerns. Recording quality of the EEG was indistinguishable to that achieved with standard gold electrodes. The use of CPEs allowed for uninterrupted EEG recording of patients who required urgent neuroimaging, and decreased the amount of time spent by the technologists required to remove and reattach leads.

Sleep-wake patterns of seizures in children with lesional epilepsy.

This study examined diurnal patterns of seizures and their occurrence during wakefulness and sleep in children with lesional focal epilepsy. We reviewed 332 consecutive children with lesional focal epilepsy and video-electroencephalogram monitoring during a 3-year period. Data were analyzed in relationship to clock time, wakefulness/sleep, and seizure localization. The distribution of lesions in 66 children (259 seizures) included mesial temporal, 29%; neocortical temporal, 18%; frontal, 29%; parietal, 13.5%; and occipital, 12%. Seizures in patients with frontal lesions occurred mostly during sleep (72%). Seizures in mesial temporal (64%), neocortical temporal (71%), and occipital (66%) lesional epilepsy occurred mostly during wakefulness. Temporal lobe seizures occurred more frequently during wakefulness (66%), compared with extratemporal seizures (32%) (odds ratio, 2.67; 95% confidence interval, 1.61-4.42). Temporal lobe seizures peaked between 9:00 am and noon and 3:00-6:00 pm, whereas extratemporal seizures peaked between 6:00-9:00 am. Sleep, not clock time, provides a more robust stimulus for seizure onset, especially for frontal lobe seizures. Temporal lobe seizures are more frequent during wakefulness than are extratemporal seizures. Circadian patterns of seizures may provide additional diagnostic and treatment options, such as differential medication dosing and sleep-schedule adjustments.

Incidence and clinical decision making for the Wada test over one decade: 1997-2007

PurposeThe objective of this study was to review the percentage of Wada tests performed on patients with intractable temporal lobe epilepsy undergoing surgery at a single epilepsy centre over the last decade, and to identify clinical features which are more likely associated with decision making in favour of Wada testing.MethodsWe retrospectively reviewed all temporal lobe resections performed between 1997 and 2007 at the Cleveland Clinic Epilepsy Center.ResultsA total of 410 Wada tests were conducted on 777 patients undergoing temporal lobectomy (TL). Left temporal resection was performed in 55% of cases. The most frequent pathological diagnoses were hippocampal sclerosis (42%) and non-specific gliosis (26%). Overall, Wada test frequency in patients undergoing presurgical evaluation decreased over time. In 1997, 47 of 58 (81%) TL patients underwent Wada testing compared to 11 of 76 (14.4%) in 2007. Patients with left temporal lobe epilepsy, and/or those referred for subdural electrode placement, were significantly more likely to undergo Wada testing. The most common types of surgery were anteromedial temporal resection with removal of mesial structures (59%) and temporal resection without mesial structure removal (32%). Patients with left temporal epilepsy and Wada testing were significantly more likely to undergo resection of mesial cortex.DiscussionWada testing has declined over the last decade in this single centre study. Patients with left, likely dominant, temporal lobe epilepsy and those with subdural evaluations were more likely to undergo Wada testing. We speculate that the emergence of alternative noninvasive language lateralization techniques, along with concerns about the reliability of results and awareness of complication risks, are major reasons for the decline.

Clinical correlations of midline spikes in children.

Here we describe the clinical characteristics of children with isolated midline spikes, comparing patients with and without epilepsy, and examining the evolution of midline spikes on repeat EEGs. EEGs and clinical information of 69 patients with isolated midline spikes identified from our EEG database were reviewed. Forty-three patients had a history of seizures. Most patients had complex partial seizures, and had an approximately five times higher chance of having new discharges at other sites on repeat EEGs than the nonepilepsy group (odds ratio=4.95). Most children without epilepsy had developmental delay, attention deficit hyperactivity disorder, and pervasive developmental disorder. Their repeat EEGs showed disappearance or persistence of the midline discharges, with a two times higher probability of normal repeat EEG (58%) than the epilepsy group (24%) (odds ratio=2.40). Isolated midline spikes may represent focal epileptiform activity, but are also found in normal children and in children with developmental and behavioral problems.

Clinical and Neuroimaging Profile of Children with Lesions in the Corpus Callosum

T2‐hyperintense signal changes in corpus callosum (CC) have been described in epilepsy and encephalitis/encephalopathy. Little is known about their pathophysiology. The aim of this study was to examine the clinical presentation and evolution of CC lesions and relationship to seizures.

TeamSTEPPS Virtual Teams: Interactive Virtual Team Training and Practice for Health Professional Learners

Medical errors because of communication failure are common in health care settings. Teamwork training, such as Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), improves team performance and patient outcomes. Academic institutions seek high-quality, low-cost curricula for interprofessional education (IPE) to prepare learners for clinical experiences before and after graduation; however, most IPE curricula involve lectures, simple tabletop exercises, and in-person simulations and are not readily accessible to geographically distributed and asynchronously engaged learners. To address this need, interprofessional faculty from multiple institutions and specialties created a series of eight screen-based interactive virtual simulation cases featuring typical clinical situations, with the goal of preparing learners to provide safe and effective care in clinical teams. Virtual simulations permit flexible, asynchronous learning on the learner’s schedule and allow educators an opportunity to identify gaps in knowledge and/or attitudes that can be addressed during class or forum discussions. In 2016, 1,128 unique users accessed the scenarios. As a result of such virtual activities, learner selection of the appropriate TeamSTEPPS tool increased with progression through the scenarios.

Statins in epilepsy Prime time? Not yet

The incidence of epilepsy has 2 peaks: early in life and after the age of 50.1 The causes of epilepsy in older adults are not well-established, but include cerebrovascular disease,2 brain tumors, and Alzheimer disease. The National General Practice Study of Epilepsy found that vascular disease accounted for 15% of newly diagnosed epilepsy in all participants, but nearly 50% in older age groups.3 That study predated the MRI era; in more recent research, more than 1 in 10 asymptomatic elderly have covert cerebral infarcts,4 suggesting an underestimate of vascular pathology in late-life epilepsy. Risk factors for seizures after ischemic stroke include the severity of neurologic disability, cortical stroke location, and hippocampal damage, with less certainty about risk factors after hemorrhagic stroke.5 Statins, blockbuster drugs for hyperlipidemia, may lower the incidence of stroke, prompting Etminan and colleagues,6 in this issue of Neurology ®, to explore a novel hypothesis, that statins reduce the risk of developing epilepsy in the elderly. The biologic plausibility of this idea has been tested in rodent models: high-dose atorvastatin reduced the frequency of clonic …

Diabetes and Parkinson disease: A sweet spot?

There are many superficial similarities between diabetes mellitus (DM) and Parkinson disease (PD). In both cases, clinical manifestations are primarily attributable to the decrement and then absence of a biological product (insulin and dopamine) with diminution and ultimately substantial or near-complete loss of cells in specialized tissue that produce the agent. The diseases affect multiple organ systems and can be treated by agonists and by replacement of the agent. Other options include stimulators, tissue transplants, and pumps. But deep down, there are biologically plausible cellular mechanisms that intertwine both of these conditions. Insulin receptors are relatively plentiful in substantia nigra neurons,1 and hyperglycemia suppresses substantia nigra dopaminergic neuronal firing as well as decreases dopamine turnover. Attention has increasingly focused on mitochondria as a link between DM and PD. Insulin resistance has been associated with mitochondrial dysfunction, while MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine), a toxin that caused numerous cases of parkinsonism, leads to mitochondrial dysfunction. Insulin resistance is associated with decreased genetic expression of peroxisome proliferator-activated receptor gamma, coactivator 1 alpha (PGC1 Alpha), a key regulator of mitochondrial genesis and functioning, with resultant organelle destruction (mitophagy), as well as increased oxidative stress and toxic mitochondrial mutations. Evidence suggests there may be diminished expression of PGC1 Alpha genes in PD as well.2

The Role of Phenytoin in the Treatment of Localization Related Epilepsy: An International Internet-Based Survey of Neurologists and Epileptologists

Phenytoin (PHT) has been the most widely used medication to treat both partial and generalized seizures. However, over the past twenty years, a variety of new compounds have been released with comparable efficacy, fewer adverse effects, and more predictable pharmacokinetic properties. We surveyed neurologists and epileptologists to determine current practice patterns relating to the use of PHT using an online survey instrument. A total of 200 responses were obtained though response rates for each survey question varied. Of the respondents, 78.1% were epilepsy specialists; 60% were adult practitioners; and the remainder saw either, only children or both adults and children. For new onset partial seizures only 10 respondents said PHT would be their first or second choice, while 45% reported that they would not consider PHT. This study shows that in the era of newer medications, the role of PHT has been placed in the category of a reserve medication in intractable epilepsy.

The role of EEG in patients with syncope.

In Reply: In their article, ‘The role of EEG in patients with syncope,’ Dantas et al. (2012) examine the utility of electroencephalography (EEG) in the routine evaluation of patients with syncope. Several issues are not clearly delineated in the article. First, the authors state that all EEGs were reported and reviewed by a board-certified neurologist and clinical neurophysiologist. Did a single individual review all the records in question or did multiple physicians evaluate these EEGs? If multiple physicians reviewed the study, did a study investigator review the EEGs again to ensure consistency? Second, did the investigators review the patient medical record to ensure that the diagnosis of syncope was appropriate and that the patients did not have subsequent events that would have confirmed a diagnosis of epilepsy? The evidence suggests that the diagnosis of syncope is arrived at in only in a third of all patients presenting with an appropriate history (Hoefnagels et al., 1992). Finally, in an otherwise well-written discussion, the authors neglect to mention an important and easy-to-use clinical diagnostic score, created by Sheldon et al. (2002) to differentiate syncope from seizure. The use of such a score based on historical criteria may go a long way to reduce excessive testing in these patients.