Ictal EEG source imaging

Background

Ictal electroencephalogram (EEG) source imaging has both advantages and disadvantages compared with source imaging of interictal epileptiform discharges. Ictal source imaging estimates the seizure onset zone directly. However, the rapid propagation of the ictal activity and the low signal-to-noise ratio impose additional challenges on ictal source imaging. Several methods have been developed to circumvent these challenges.

Objectives

To summarize and explain in plain terms the methods of ictal EEG source imaging and to review the published evidence on its accuracy.

Materials and methods

We systematically searched Medline for studies of ictal EEG source imaging. In addition, we summarize our clinical experience with ictal EEG source imaging and we present illustrative examples for the analysis process.

Results

Pooled data from 77 operated patients, from four clinical studies, showed that ictal EEG source imaging had a sensitivity of 83.3% (95% confidence interval: 69.8–92.5%) and specificity of 72.4% (95% confidence interval: 52.8–87.3%).

Conclusion

Ictal EEG source imaging is accurate and it should be added to the multimodal presurgical evaluation of patients with drug-resistant focal epilepsy.

     

Epilepsie – neue Diagnostik,alte Medikamente?

Background

Recent advances in the field of epilepsy genetics have led to an increased fraction of patients with epilepsies where the etiology of the disease could be identified. Nevertheless, there is some criticism regarding the use of epilepsy genetics because in many cases the identification of a pathogenetic mutation does not lead to an adaptation of therapy or to an improved prognosis. In addition, the interpretation of genetic results might be complicated due to the considerable numbers of variants of unclear significance.

Objective

This publication presents the arguments in favour of a broad use of genetic investigations for children with epilepsies. Several diseases where a genetic diagnosis does in fact have direct therapeutic consequences are mentioned. In addition, the indirect impact of an established etiology, encompassing the avoidance of unnecessary diagnostic measures, possibility of genetic counselling, and the easing of the psychologic burden for the caregivers, should not be underestimated.

Conclusion

The arguments in favour of broad genetic diagnostics prevail notwithstanding the lack of relevant new developments regarding the therapy.

     

Nonkonvulsiver Status epilepticus

Background

Nonconvulsive status epilepticus (NCSE) is associated with a poor outcome and is furthermore a diagnostic challenge in routine clinical work.

Objective

Several sets of diagnostic criteria exist. What is the difference between them and which ones have been evaluated? Which concept can be recommended in the light of current knowledge?

Material and methods

A survey on the current literature is provided and a structured approach for diagnosing NCSE is given.

Results

Only one study on evaluation of the diagnostic criteria for NCSE exists, i.?e. the “Salzburg criteria for NCSE”, which were investigated retrospectively in a multicenter study. The diagnosis of NCSE is based on clinical and EEG data. The additional implementation of paraclinical information, such as cerebral imaging, emergency and toxicology laboratories is mandatory.

Conclusion

Currently available criteria enable efficient and effective management of the majority of patients suspected of having NCSE; however, in individual cases it has to be taken into consideration that the criteria can be falsely positive or falsely negative.

     

Antikonvulsive Behandlung bei Kindern mit therapieschwierigen Epilepsien

Objective

In the present study we reviewed possible strategies and their success rates following primary therapy failure.

Material and Methods

From all outpatients, we evaluated those children who had previously been treated unsuccessfully with two or more anticonvulsants, suffering from active epilepsy for at least one year and who had the last therapeutic intervention at least six months ago (n = 103). Regarding etiology, three groups were distinguished. The endpoint was seizure frequency. We distinguished between seizure freedom, seizure reduction by 75?% (responder) and no substantial improvement.

Results

Of 103 patients, 45 were seizure-free, 45 were responder and 13 patients did not benefit.

Discussion

An important advantage for patients that ultimately contributed significantly to the success of treatment was re-evaluation of the diagnosis and classification of the epilepsy. By correcting diagnosis and consequently changing treatment, some cases were successfully treated. All therapeutic options could be offered, including the full range of available anticonvulsants, surgical treatment and ketogenic diet. The majority of treatment success was achieved by consistent anticonvulsant pharmacotherapy regime. It was found that good therapeutic success was achieved most frequently with valproate and lamotrigine, without a significant difference regarding the epilepsy syndromes.

     

Telemedizinische Voranmeldung in der akuten Schlaganfallversorgung

Objective

The Stroke Angel initiative investigates the implementation of telemedicine for improvement of preclinical communication between emergency medical services (EMS) and stroke units in cases of acute stroke.

Material and methods

Stroke Angel is a technical system for the telemedical prenotification of patients in cases of suspected stroke at a stroke unit by the EMS. Within the framework of an observational study, the team has been investigating the effects of the system on door-to-computed tomography (CT) and door-to-needle times as well as the lysis rate in the neighboring regions of Rhön-Grabfeld and Bad Kissingen since 2005.

Results

The system supports the acute treatment of neurological emergencies and functions as a catalyst for the interlinking of medical institutions in the region as well as for communication between emergency physicians/EMS and hospital physicians. The use of a computer-based data collection enables a continuous improvement process leading to an acceleration of internal clinical procedures and an increase of the lysis rate with the mortality rate staying constant.

Conclusion

Telemedicine is applicable in the preclinical care of acute stroke and, thanks to the computer-based data collection, leads to an increase in process transparency, which helps to improve the internal clinical processes in and around a stroke unit.

     

Suizidalität in der Adoleszenz

Background

Suicide is one of the four most common causes of death in adolescence worldwide. Although it is well known that suicidal people often have insufficient communication strategies, the importance of family communication for adolescent suicidality has not yet been sufficiently explored.

Objective

The aim of this study was to provide a systematic review of family communication as a risk factor for adolescent suicidal tendencies and to develop treatment recommendations.

Methods

In this study a systematic literature search was conducted in PubMed, Embase, CENTRAL and PsychINFO. The methodological quality of the studies was evaluated and a summary prepared.

Result

A total of 195 studies were extracted and screened for their suitability. Of these studies, 7 which examined a total of 13,107 adolescents aged 11–22 years were included in this review and critically evaluated. Of the studies evaluated six found a correlative relationship between dysfunctional parent-child communication and adolescent suicidality. Communication with the mother appears to be more essential.

Conclusion

The results of this literature search indicate that functional communication with parents seems to be protective for suicidal adolescents. From this, recommendations can be derived for preventive measures in families with adolescents who are otherwise at increased risk of suicide. Longitudinal study designs are needed to conclusively answer the research question.

     

Stalking von Psychiatern und Psychotherapeuten

Background

Currently, there are clear indications that due to their exposed occupational position psychiatrists and psychotherapists are at a higher risk than the general public to become the victim of stalking by patients.

Objectives

This study investigated the frequency of stalking and its psychosocial impact among psychiatrists and psychotherapists in the Federal Republic of Germany.

Methods

Analysis of an online survey among members of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) from 23 September 2015 until 22 October 2015.

Results

Of the respondents 26.5% reported having been the victim of stalking. In more than a third of the reported cases the stalking was described as severely or very severely debilitating. The majority of the perpetrators suffered from psychotic or personality disorders. Male victims were significantly more frequently stalked by a female perpetrator. Approximately 1 in 10 stalking victims continued the treatment of the perpetrator. The majority of the stalking victims did not obtain substantial support from their employer.

Conslusion

The phenomenon of stalking within therapeutic relationships needs to be incorporated into the medical and psychotherapeutic professional training, e.?g. by implementing specialized training courses and the systematic integration of this topic into clinical supervision. The institutional dealing with stalking by patients needs to optimized, e.?g. by promptly transferring treatment of patients who stalk to other professionals and, where required, providing assistance in reporting stalking incidents to the police.

     

Comparative role of neuropsychological testing in the presurgical evaluation of children with medically intractable epilepsies

Purpose

In the present study, we evaluated the preoperative demographic, clinical, and neuropsychological variables that could predict postoperative seizure outcome in a group of pediatric epileptic patients.

Materials and methods

We studied 40 consecutive pediatric patients, ages ranging from 6 to 16 years, that underwent resective surgery for the treatment of medically intractable epilepsy at the Clinical Hospital of Ribeirão Preto School of Medicine. We performed ictal electroencephalography (EEG), interictal EEG, magnetic resonance imaging (MRI), and a preoperative neuropsychological assessment in the presurgical workup.

Results

The following factors were correlated with seizure outcome: (1) duration of epilepsy, (2) surgery localization, (3) localized Neuropsychological (NPS) Evaluation, (4) ictal EEG, (5) interictal EEG, and (6) MRI. Mental retardation, NPS tests, and the other demographic variables failed to correlate with seizure reduction.

Conclusions

The identification of predictor variables of epilepsy surgery outcome could improve the epileptic prognosis and guarantee the children's full potential development.

     

Therapieabbruch als Prädiktor erneuter Straftaten

Background

Recidivism rates in substance-addicted patients placed in institutions according to §64 of the German legal code are approximately 50%, 3 years after discharge from inpatient treatment. The recidivism rates of patients with premature termination of inpatient treatment who had then been referred back to prison and were finally discharged into the community are unknown.

Research question

Is premature termination of treatment a risk factor for recidivism?

Methods

Patients released from forensic treatment according to § 64 of the German legal code were followed up for violent and non-violent recidivism. Full data were acquired for Baden-Württemberg patients released in 2010 and 2011 with regular vs. premature termination of treatment.

Results

All measures revealed highly significant group differences: 48% of the patients discharged after subsequent prison sentences recidivated within the first year and 73% within 3 years after discharge. Among recidivists, the severity of offences was much higher (odds ratio > 3.8 each). Regularly discharged patients also re-offended to a remarkable extent (50%).

Discussion

Patients serving prison sentences after unsuccessful forensic treatment are a high-risk group for recidivism. Alternative concepts of clinical and legal treatment of this group should be developed.

     

Die neue Anfalls- und Epilepsieklassifikation im klinischen Alltag

Background

In 2017, the International League Against Epilepsy (ILAE) published a new seizure and epilepsy classification. After this publication, there has been considerable doubt whether this classification can be translated into German and whether it is easy to apply in everyday clinical practice.

Objectives

To investigate to what extent the new classification is employed in the doctors’ letters of our clinic.

Materials and methods

We retrospectively analyzed the most recent doctors’ letters before 01 December 2017 and examined whether the new classification was applied and what kind of changes were especially frequently not adopted. Furthermore, our clinic’s physicians anonymously answered our questions about knowledge, appreciation and use of the new classification.

Results

The new classification was entirely applied in 28 of 76 letters (37%). The most common reason for not implementing the new classification correctly was using prior seizure denominations, as bilateral convulsive seizures (n?=?15), dyscognitive seizures (n?=?9) and aura (n?=?6). Only with regard to generalized epilepsy syndromes were there no difficulties in adopting the new classification.

Conclusions

In our specialised centre, physicians applied the new classification only in one third of all cases, despite subjective predominantly good knowledge of the new classification. The acceptance of the new ILAE version was diverging in our physician staff. It seems likely that some officially abolished terms which have proven their worth by being comprehensible and feasible will persist in our vocabulary.

     

Neue Definition und Klassifikation des Status epilepticus – Was ändert sich für die Praxis?

Background

Status epilepticus (SE) is an epileptic complication of neurological disorders and associated with a poor outcome. The early diagnosis and treatment are of paramount importance. In 2015 the International League Against Epilepsy (ILAE) proposed a new set of diagnostic criteria and a classification of SE.

Objective

What will change in daily practical work due to the new ILAE 2015 criteria for SE?

Material and methods

A survey on the current literature and a detailed presentation of the criteria for diagnosis and classification regarding ILAE 2015 are provided.

Results

Bilateral tonic-clonic seizures in SE (convulsive SE) are diagnosed after 5 min (time T1) in order for treatment to be successful within 30?min (time T2) to prevent permanent neuronal damage. In cases of focal seizures with or without impaired consciousness or absence status, the diagnosis and initiation of treatment should be made within 10?min. Regarding the time period T2 there is only limited evidence available. The most important semiological criteria are the differentiation according to the presence or absence of prominent motor phenomena and the state of consciousness. Further taxonomic axes are the etiology, EEG and age. In a retrospective study the applicability of the criteria was good.

Conclusion

The ILAE 2015 definition and classification are transparent, clear, well arranged and easily applicable in routine clinical work. The simultaneous semiological classification of motor phenomena and impairment of consciousness is the most important scientific advantage.

     

„Mission (im)possible“

Background

Specialized neurological treatment decreases the mortality and morbidity of stroke patients. In many regions of the world an extensive coverage is not available. The cooperation between the Krankenhaus Nordwest (KHNW, Frankfurt, Germany) and the Government of Brunei Darussalam describes the set-up process of a specialized neurological center, including stroke unit, science and rehabilitation center.

Aim

The aim of this project called to teach to treat – to treat to teach was to set up a center of excellence in neurology in Brunei Darussalam over a distance of 12,000?km. Treatment options were elucidated by teaching and taught by case examples.

Material and methods

The construction of the Brunei Neuroscience Stroke and Rehabilitation Center (BNSRC) began in July 2010. To overcome the large distance between the department of neurology and neuroradiology at the KHNW and the BNSRC, a telemedical network was established. We provided daily teleteaching for all professions involved in patient care as well as 24/7 availability of teleneurological services from Germany to support the local team on site.

Results

In the BNSRC unit over 1000 patients with ischemic and hemorrhagic stroke and all the various acute neurological conditions were treated from July 2010 until July 2016 as inpatients and over 5000 were treated as outpatients. Since 2010, a total of 52 patients with stroke were treated by thrombolysis within the thrombolytic window and 81 hemicraniectomies were performed.

Conclusion

The project has shown that it is possible to convey specialized neurological knowledge over large distances to provide significant benefits for patients and caregivers.

     

Deutschlandweite Evaluation der ärztlichen Weiterbildung in der klinischen Neurologie

Background

Currently, no data are available, which reflect the situation of medical doctors specializing in neurology in German hospitals. In order to secure the high standard of neurological patient care it is essential to evaluate the working conditions and the specialty training in neurology.

Objective

This nationwide survey was conducted throughout Germany with the aim to address problems and to give suggestions for improvements in neurological training curricula.

Material and methods

The survey was online from February to May 2017 and 953 neurologists undergoing further training participated.

Results

More than half of the young neurologists were satisfied with their medical training. One of the main problems that complicates clinical training is the workload. In addition, organizational obstacles within the clinic, such as poor structure of education or a lack of mentors, lead to dissatisfaction among participants. The size or type of the department, as well as the prevailing service system, exert only a minor influence on the quality of specialist training, although there were differences especially in the self-assessment of the participants in connection with the type of department (university hospital versus public or private hospital).

Conclusion

Specialist training in neurology can be improved by simple arrangements, e.?g., the introduction of a binding rotation scheme, internal mentoring and structured feedback. In addition, it will be necessary to relieve medical staff of administrative duties in order to create time for training and the learning of competencies.

     

Therapeutic coma for the treatment of status epilepticus

Background

There are scarce data available on the treatment of refractory status epilepticus (SE) where general anesthetics are recommended. However, these may be related to increased morbidity (and possibly mortality).

Question

When and how should therapeutic coma be used in this clinical setting?

Methods

Critical review of available international literature in the past 50 years as well as of personal experience.

Results

Patients with generalized convulsive or nonconvulsive SE in coma not responding to benzodiazepines and an antiepileptic drug should be treated under electroencephalographic (EEG) monitoring with coma induction and general anesthetics. Initially, midazolam/propofol seem to represent the safest options. A progressive weaning attempt should be made after 24?h without EEG seizures. Patients with absence SE should never be treated with coma, and in those with focal SE with preserved consciousness coma should be deferred after the trial of other nonsedating compounds. In cases of super-refractory SE, ketamine and/or a ketogenic diet may be considered.

Conclusion

In view of the limited current evidence, it seems reasonable to avoid indiscriminate use of general anesthetics in SE.

     

Krankheitskosten und Outcome: Versorgungsrealität des Status epilepticus

Background

In times of an increasing economic impact on healthcare systems the collection, processing and analysis of disease-specific costs becomes more and more relevant. This is particularly true for chronic diseases, such as epilepsy where the focus of interest is due to the high direct and indirect costs of the disease. The additional economic impact of status epilepticus (SE) is under-represented in the few available cost of illness studies (COI).

Objective

The systematic analysis and comparison of disease-specific costs and mortality of SE in Germany and other countries.

Methods

A systematic combined literature search was performed via the PubMed gateway in June 2018.

Results

A total number of three COI studies was available on SE in Germany. The median direct costs amounted to ca. 4000–15,000?€ per stay with a mean length of stay (LOS) of 1–2 weeks. The inhospital mortality was 10–15%. For patients with non-refractory SE (NSE) average costs were calculated as 4500–5500?€ (mortality 10%, LOS 8 days), whereas refractory SE (RSE) accounted for 4500–13,500?€ (mortality 15%, LOS 14 days) and super-RSE (SRSE) 33,000–50,500?€ (mortality 40%, LOS 37 days). These results are comparable to other COI studies on SE from Australia, India and the USA.

Conclusion

From both health-economic and healthcare perspectives SE represents a relevant disease manifestation. Further studies to collate the incidence, mortality and costs are urgently needed in view of the increasing number of treatment options.

     

Wahn: aktuelle psychodynamische und neurokognitive Ansätze

Background

The symptom “delusions” is a central psychopathological symptom in psychiatric diseases. Since the beginning of psychiatry various disciplines have attempted to explain and understand delusions but even now no generally accepted definition of this phenomenon exists.

Aim

A comprehensive review of current psychopathological and neurobiological theories of delusions is given.

Material and methods

PubMed and Google scholar searches were performed using the keywords “delusion”, “psychodynamic” and “neurobiology”, both in English and German. Relevant German textbooks of psychiatry were also included.

Discussion

A differentiated perspective of the phenomenon of delusions appears to be necessary to approach this complex and fascinating symptom. A one-dimensional approach does not do justice to the complexity of delusions. The various explanatory approaches can increasingly be linked to each other and are no longer considered to be mutually exclusive.

     

Epilepsy surgery for pediatric low-grade gliomas of the cerebral hemispheres: neurosurgical considerations and outcomes

Introduction

Pediatric low-grade tumors are found in roughly 1–3 % of patients with childhood epilepsy; seizures associated with these tumors are often medically refractory and often present a significant morbidity, greater than the presence of the tumor itself.

Discussion

The unique morbidity of the seizures often requires an epilepsy surgical approach over a standard oncologic resection to achieve a reduction in morbidity for the child. Multiple quality-of-life studies have shown that unless a patient is seizure-free, they remain disabled throughout their life; the best way to achieve this in our patient population is with a multidisciplinary team approach with treatment goals focusing primarily on the epilepsy.

Conclusion

In those patients treated with gross total resection, roughly 80 % will have an Engel class I outcome and 90 % will achieve some reduction in seizure frequency with a significant improvement in quality of life.

     

Konversionen von kognitiven Screenings

Background

For a comprehensive specification and quantification of neuropsychological deficits, extensive neuropsychological assessment is needed. Due to its time intensiveness, this cannot be accomplished in every clinical setting and is not always necessary. Therefore, screening instruments provide a first step. Because the selection differs between and sometimes even within clinics, a comparison of results for different screening procedures would be helpful. The current study aimed at achieving this in the German-speaking area, i.e. conversions between sum scores of the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and Dementia Detection Test (DemTect) can be accomplished.

Method

In the Department of Neurology at the University Hospital of Cologne, 8240 patients with different neurological diseases were examined between 2008 and 2017. Conversion scores using the results in the MMSE, MoCA and DemTect were computed by using the equipercentile equating method.

Results

The calculated bidirectional conversion tables enable a quick and easy comparison between the three most commonly used screening instruments. They are also similar to those from previous studies in English-speaking countries.

Conclusion

The results enable an enhanced longitudinal assessment of cognitive functions in different clinical settings, provide comparability, and offer more flexibility for determination of patient status. An extension of the current study might be the transfer of the method presented to other cognitive or affective domains, such as memory and depression.