EEG technique and Treatment of Rolandic Epilepsy treatment?.

Looking at the EEG patterns periodically at certain time difference, could be week or month in between, Yamanashi and his colleague found that there is a repetitive high frequency EEG waveform abnormality that can be used to strategies for treatment?. Although, it is a brief study on small number of children's, EEG recordings and the abnormal waveform morphology is one of the or the only way to ascertain what to do with such epileptic patient, actually, while referring to the recent reviews in this field, I found this compelling review article   by Dr.Markand, MD (see at the bottom after the Yamanashi's work).

What was their research model and study is about:

A total of ten children between the ages of three and ten with recurrent seizures and 12 patients aged between four and seven years who experienced isolated seizures were enrolled in the study, with seizure recurrence and prolonged high-frequency EEG paroxysm data being correlated by the scientists.
Repeated EEG recordings were taken every three months, with clinical and EEG follow-up performed for four or more years. It was discovered that seizure recurrence and extended periods of high-frequency paroxysmal EEG abnormalities for more than 6 months after onset were significantly linked.

New study shows how EEG can aid rolandic epilepsy treatment

Posted May 21 2014 in epilepsy in children and its treatment

A new study from Japan has shed light on how electroencephalogram (EEG) techniques can be useful in aiding the treatment of patients with rolandic epilepsy.

This form of epilepsy is generally associated with favourable outcomes, with a moderate proportion of cases characterised by isolated seizure events, meaning continuous treatment need only be considered only for those affected by frequent seizures.

As such, the new research from the University of Yamanashi aimed to identify EEG criteria related to seizure recurrence in rolandic epilepsy, in order to help guide treatment strategies for those in this patient group.


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The review article that I mentioned above:

a good read to get the background idea of how the neurophysiologist, neurologist or clinicians can discern the EEG patterns:

Seminars in Neurology

Pearls, Perils, and Pitfalls In the Use of the Electroencephalogram

Omkar N. Markand, MD, FRCPC

 An EEG is the most common and most useful test performed in evaluating patients suspected of epilepsy. There are many areas where an EEG has unique contributions. The value of an EEG lies in the fact that it not only shows specific ictal discharges during a clinical seizure but also characteristic epileptiform abnormalities in a high proportion of epileptic patients even in the interictal period. Furthermore, an EEG may be the only test demonstrating focal abnormalities responsible for the patient's epileptic seizures. Specific patterns in the EEG make it possible to classify the seizure type, which is an essential prerequisite to institute proper antiepileptic medication. An EEG is indispensable for the diagnosis of nonconvulsive epileptic status presenting as prolonged "twilight" state or a prolonged episode of abnormal behavior. In a patient with bizarre motor activity, the recording of an EEG during such an episode may be the only way to establish whether the abnormal behavior is due to an epileptic seizure or a nonepileptic event, physiologic or nonphysiologic. Finally, the EEG is indispensable to localize the epileptogenic (seizure producing) zone before resective surgery (excision of the epileptogenic zone) is undertaken in a patient with medically refractory focal epilepsy.

Vascular Complications During Thoracic Pedicle Screw Placement: What?. Is this even Possible, yes!.

Surgery insight: During surgical performance or surgical procedures and providing patient care, there is nothing like oh you mean that?, well that is very simple or take for granted in a casual way, one must show at most attention and care in every small to big steps, so do the neuromonitoring and anesthesia professionals, you can be of great help to surgeon when you detect changes or unusual activity that can get surgeons attention right away. Ofcourse for surgeons, there is no room for error but absolutely there is no room for Oh I have done 1000s of surgery, pricking a nerve or artery during my pedicle screw insertion is not going to happen, oh well, it did. The following paper describes a case and death of a patient two weeks after the surgery, so be diligent.

While reading this article :Thoracic pedicle screw placement: Free-hand technique  by Yongjung J. Kim, Lawrence G. Lenke regarding Scoliosis and thoraci pedicle screw placement, I came across the two back reference that startled me, an important and interesting reference about how vascular complications can occur by careless pedicle screw placement?..

Vascular complications 

22.Heini P, Scholl E, Wyler D, Eggli S. Fatal cardiac tamponade associated with posterior 
spinal instrumentation. A case report. Spine 1998;23:2226–30.  

Heini et al[22] described a case of fatal cardiac tamponade that
was due to a prick injury of the right coronary artery by a Kirschner
Neurology India | December 2005 | Vol 53 | Issue 4
CMYK517 517 Kim et al: Thoracic pedicle screw placement
wire. The injury was confirmed by autopsy after the patient died
12 days after surgery.

14. Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER. Thoracic pedicle screw fixation in 
spinal deformities: are they really safe? Spine 2001;26:2049–57.   

Suk et al [14] described a case of an over­penetrated screw causing irritation of the thoracic aorta resulting in severe chest pain.

 25. Minor ME, Morrissey NJ, Peress R, Carroccio A, Ellozy S, Agarwal G, et al. 
Endovascular treatment of an iatrogenic thoracic aortic injury after spinal 
instrumentation: case report. J Vasc Surg 2004;39:893–6

 Recently Minor et al [25] reported endovascular  treatment of an iatrogenic aortic injury by misplaced thoracic pedicle screw at T5. 

I have not yet read all these three papers, I will comment further after I go through them all.

Review of Neuromonitoring field 32 Years Ago?.

The utilization and importance of Neuromonitoring in hospital or intensive care set up was reviewed elaborately 32 years ago during 1985. Did anything change or how much change has took place in this field is quite interesting, while basic principles and intraoperative modalities discussed remain pretty much same today as 32 years ago, IONM field did make lots of progress ever since, better tests, analysis and interpretation of results got savvy and reliable upto 96-99% accuracy than it was during1985. Advancements in terms of application in various surgical procedure and combinatorial tests to yield better results, some newer techniques, and the entire hardware/machine technology certainly been upgraded to fit the Operating Room environment.

W.Hacks, the author of this review from the then FRG (West Germany, no longer the case after 90s unified Germany) made a remarkable attempt to provide insights 32 years ago. The review has been published in "Journal of Neurology (interestingly, the very first issue of this journal was published way back in the year 1891 that continued till today with the same name Journal of Neurology Volume 1 / 1891 - Volume 259 / 2012), quite an respectable journal in the field of neurology, it is still exist with the same name with a significant impact factor score of 3.85, ranked 33 among 185 clinical neurology journals [The top five Neurology journals are rated as follows:  (Neurology, Brain, Annals of Neurology, Journal of Neurotrauma, and Stroke, for an interesting review of these top journals, click here LINK).

Here is the link to the partial or one page review available at the bottom of this abstract, it is a pay per view article, only one page is viewable for non subscribers.

Abstract

Neuromonitoring—the continuous or intermittent observation of nervous system functions—has become a field of interdisciplinary interest. Basically there are two major applications of neuromonitoring: in the operating theatre and the neurological or neurosurgical intensive care unit. Evoked potential recording, intracranial pressure measurement, serial EEG recording, cerebral blood flow measurement and ultrasound techniques have all been used as monitoring methods. The application of these techniques for operations, intensive care and the evaluation of brain death will be described.

Key words  Neuromonitoring - Intraoperative monitoring - Evoked potential monitoring - Spinal cord monitoring - Brain death

http://resources.metapress.com/pdf-preview.axd?code=kpj1622557hv431x&size=largest

Neuromonitoring:- a Review on PubMed Publications

We do not get much time to go read all the published papers on Neuromonitoring, unlike during the Laboratory research days, my visit to PubMed is less frequent, but yet I do not give up on my practice to go here and spend some time in catching up with the latest papers.  In my recent visit to the PubMed, I found the following ongoing research activities in the field of neuromonitoring. 

This is a very brief review, will help re-route the interested readers or visitors to the PubMed original article. Right now, I have access to only the abstracts, so just by going through the abstracts of recently published article I thought to list the recent papers here. 

PubMed Search "Neuromonitoring" check the links direct to the articles.

1.Therapeutic hypothermia for cardiac arrest: a practical approach.

Curr Treat Options Neurol. 2009 Mar;11(2):137-49.

Seder DB, Jarrah S argues that though Therapeutic Hypothermia (TH) is the most immediate and well known technique to review patients suffering from cardiac arrest (known as Encephalopathic survivors), a combined approach that involves various emerging tools such as critical care or Neuromonitoring can yield better outcome of patients, usage of neuromonitoring is critical during decooling phase...!

In the same journal of Curr Treat Options Neurol, another article emphasize the knowledge and usage of multimodality neuromonitoring for better outcome of patients aneurysmal subarachnoid hemorrhage (SAH)

a non traumatic hemmorrhage caused by either a tumor,infection or vascular malformation. 

2.Critical care management of subarachnoid hemorrhage."This article reviews the natural history of aneurysmal SAH and

strategies for disease management in the acute setting, including available tools for monitoring brain function.

Intensive care management of patients with SAH focuses on prevention of further neurologic injury. Aneurysmal rebleeding, hydrocephalus, seizures, and delayed ischemic injury represent major threats"

In vascular surgeries like carotid endarterectomy and when the internal carotid artery (ICA) is clamped the neuromonitoring playes an important role in giving early warning of Ischemia or embolism, especially the Sensory evoked potential and EEG monitoring.  Some of the techniques used are Transcranial Doppler (TCD) to measure the mean blood flow velocity, and Near-infrared Spectroscopy (NIRS) to assess the dynamics of "haemoglobine", but these techniques according to Bein B, Fudickar A, Scholz J. the practicability of using TCD and NIRS posses problems in about 20% patients?. Bein et all suggests the "Gold Standard" for better outcome and patient safety is to use intraoperative monitoring of SSEP?.

 3. [Anesthesia in vascular surgery--monitoring of cerebral function].

"Use of somatosensory evoked potentials (SEP) is the most widespread cerebral neuromonitoring during vascular surgery due to its high reliability and simple application. Sensitivity and specifity for ischemic lesions are 100% and 94%-99%, respectively. SEP are regarded as the gold standard for cerebral neuromonitoring in anaesthetized patients".

 Br J of Surg , In this British Journal of Surgery Publication,

4. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy.  Barczyński M, Konturek A, Cichoń S discuss about testing the hypothesis "Neuromonitoring of Recurrent Layrngeal nerves during Thyroidectomy?.  Unlike Barczyriski et al., who concluded the that the neuromonitoring in their surgical procedures

"Nerve monitoring decreased the incidence of transient but not permanent RLN paresis compared with visualization alone, particularly in high-risk patients".

These Italian surgery team in  video-assisted thyroidectomy (VAT) a same day surgical procedure, they found Intraoperative monitoring of reccurrent laryngeal monitoring helped prevent permanent damages to laryngeal nerves. 

5. Video-assisted thyroidectomy performed in a one-day surgery setting.

"Intraoperative neuromonitoring (IONM) was used for RLN identification. Intact parathyroid hormone (iPTH) levels were determined early postoperatively at +6-h. Postoperative complications, conversion rate were analyzed. RESULTS: No cases required conversion to open surgery or ordinary recovery (i.e. >24h). Incidence of temporary hypoparathyroidism was 11.6% (5/43) with no case of symptomatic hypocalcemia. Incidence of temporary RLN injury was 2.3% (1 patient) with no case of permanent or bilateral RLN injury. All patients were satisfied with the type of recovery. CONCLUSIONS: This preliminary report is an example of the safe incorporation between new technologies (IONM, early iPTH measurement) with improvement of the quality and safety of VAT performed in a one-day surgery setting. (this is a Dec 2008 article, not 2009?)

 6. In this latest issue of Laryngoscope, risks of VOICE alterations? (vocal cord damage due to laryngeal nerve injury) has been discussed. The Columbia University surgical team presents their data in this interesting finding and the authors conclude that there was 100% preservation of vocal cords during this minimally invasive, local anesthesia induced thyroidectomy.  The authors 

"Inabnet WB, Murry T, Dhiman S, Aviv J, Lifante JC discuss that the dentification and preservation of the external branch of the superior laryngeal nerve (EBSLN) is paramount for normal vocal function preservation after thyroidectomy. 

Thyroidectomy was successfully completed under local anesthesia in all cases. The recurrent laryngeal nerve(s) was identified and preserved in each patient as demonstrated by normal perioperative transnasal flexible laryngoscopy.

A total of 15 EBSLNs were at risk, but only 8 EBSLNs (53%) were definitively identified.

 Neuromonitoringdemonstrated preservation of the EBSLN in 100% of cases.

The analysis of the results of the VHI-10 questionnaire before and 3 weeks after surgery indicated no significant change in patients' perception of voice severity. CONCLUSION:: Monitoring of the EBSLN during thyroidectomy under local anesthesia is a feasible alternative to conventional nerve monitoring under general anesthesia. This technique may be useful for the preservation of voice quality during a minimally invasive thyroidectomy under local anesthesia"

Neurophysiology Recitation of Texts Only: 1824-1889?

Today, we have the most sophisticated tools to study and learn science and medical subjects. Most of the ground breaking scientific and medical findings came out of a laboratory research that involves animal research or human research, without practical research, can't imagine the fate of our medical and scientific achievements. If that is true for general science and medical field, the progress we made in neuroscience in general and clinical neuroscience like Neurophysiology and Intraoperative neuromonitoring is an amazing break through of our learning using modern tools. What were they during just 200 years ago in physiology and neurophysiology?. Not much.......... Physiology was studied and taught by only reciting the texts like some of those Jabber's of religious scriptures in temples, really?. 

Yes, 

it seems during early to late 1800's the Physiology was taught by reciting the texts. For the very first time live animal demonstration in anesthetized animals was introduced in America by Dalton.

Neurology 2000;55:859-864
© 2000 American Academy of Neurology 

---

Historical Neurology

John Call Dalton, Jr., MD

America’s first neurophysiologist

Edward J. Fine, MD, Tara Manteghi, BA, Sidney H. Sobel, MD and Linda A. Lohr, MA

From the Department of Veterans’ Affairs Medical Center and Department of Neurology (Dr. Fine and Ms. Manteghi), State University of New York at Buffalo; Finger Lakes Radiation Oncology (Dr. Sobel), Clifton Springs, NY; and the Robert L. Brown, MD, History of Medicine Collection (Ms. Lohr), State University at Buffalo, NY.

Address correspondence and reprint requests to Dr. Edward J. Fine, Neurology Service, Department of Veterans’ Affairs Medical Center, 3495 Bailey Avenue, Buffalo, NY 14215.

Before the discoveries of John Call Dalton, Jr., MD (1824–1889), innervation of laryngeal muscles, long-term effects of cerebellar lesions, and consequences of raised intracranial pressure were poorly understood. Dalton discovered that the posterior cricoarytenoid muscles adducted the vocal cords during inspiration. He confirmed Flourens’ observations that acute ablation of the cerebellum of pigeons caused loss of coordination. Dalton observed that properly cared for pigeons gradually recovered "coordinating power." Dalton observed that prolonged raised intracranial pressure caused tachycardia and then fatal bradycardia in dogs. Before Dalton published his photographic atlas of the human brain, neuroanatomy atlases were sketched by Europeans and imported into the United States. Dalton’s atlas of the human brain contained precise photographs of vertical and horizontal sections that equal modern works. Before Dalton introduced live demonstrations of animals, physiology was taught by recitation of texts only. Dalton was the first American-born professor to teach physiology employing demonstrations of live animals operated on under ether anesthesia. He wrote an essay advocating experimentation on animals as the proper method of acquiring knowledge of function and that humane animal experimentation would ultimately improve the health of man and animals. His eloquent advocacy for humane experimental physiology quelled attacks by contemporaneous antivivisectionists. Dalton was America’s first experimental neurophysiologist.

Spinal Cord Injury & the debilitating condition!

Why neuroregeneration research, stem cells and its research are important to this world?.
Just watch this video, put your few min aside to see this spinal cord injury and its impact on Mike's life...!?

Some Stats about CNIM Exam

CNIM Written Exam 2003-2006
One of the following must be met and verified for candidates

to be eligible to take the CNIM Exam:

Health care credential plus documentation of 100 cases monitored
Bachelor’s degree plus documentation of 100 cases monitored
68% passed on their first attempt. The pass rate for repeaters was 46%.
39% had another health care credential. Their pass rate was 50%.
61% of candidates had a bachelor’s degree or higher and a 61% pass rate.
Some of the candidates with bachelor’s or advanced degrees, also documented they had another health care credential.
Procedures Performed in the OR Totals
Totals Percentage
Spinal Nerve EMG 911 83%
Motor Pathway 783 71%
Intraop Scalp EEG 719 65%
BAEP 661 60%
Cranial Nerve EMG 619 56%
Cortical mapping 337 31%
ECOG 197 18%
VEP 139 13%

41% of candidates stated CNIM was a Job Requirement. This was the most common reason stated for taking the exam. The second most common response was Professional Advancement (34%) and the third reason selected was Personal Goal (18%).