Interrater variability of EEG interpretation in comatose cardiac arrest patients.

OBJECTIVE: EEG is widely used to predict outcome in comatose cardiac arrest patients, but its value has been limited by lack of a uniform classification. We used the EEG terminology proposed by the American Clinical Neurophysiology Society (ACNS) to assess interrater variability in a cohort of cardiac arrest patients included in the Target Temperature Management trial. The main objective was to evaluate if malignant EEG-patterns could reliably be identified. METHODS: Full-length EEGs from 103 comatose cardiac arrest patients were interpreted by four EEG-specialists with different nationalities who were blinded for patient outcome. Percent agreement and kappa (κ) for the categories in the ACNS EEG terminology and for prespecified malignant EEG-patterns were calculated. RESULTS: There was substantial interrater agreement (κ 0.71) for highly malignant patterns and moderate agreement (κ 0.42) for malignant patterns. Substantial agreement was found for malignant periodic or rhythmic patterns (κ 0.72) while agreement for identifying an unreactive EEG was fair (κ 0.26). CONCLUSIONS: The ACNS EEG terminology can be used to identify highly malignant EEG-patterns in post cardiac arrest patients in an international context with high reliability. SIGNIFICANCE: The establishment of strict criteria with high transferability between interpreters will increase the usefulness of routine EEG to assess neurological prognosis after cardiac arrest.

EEG as an Indicator of Cerebral Functioning in Postanoxic Coma.

Postanoxic coma after cardiac arrest is one of the most serious acute cerebral conditions and a frequent cause of admission to critical care units. Given substantial improvement of outcome over the recent years, a reliable and timely assessment of clinical evolution and prognosis is essential in this context, but may be challenging. In addition to the classic neurologic examination, EEG is increasingly emerging as an important tool to assess cerebral functions noninvasively. Although targeted temperature management and related sedation may delay clinical assessment, EEG provides accurate prognostic information in the early phase of coma. Here, the most frequently encountered EEG patterns in postanoxic coma are summarized and their relations with outcome prediction are discussed. This article also addresses the influence of targeted temperature management on brain signals and the implication of the evolution of EEG patterns over time. Finally, the article ends with a view of the future prospects for EEG in postanoxic management and prognostication.

Clinical Use of EEG in the ICU: Technical Setting.

Neurophysiology is an essential tool for clinicians dealing with patients in the intensive care unit. Because of consciousness disorders, clinical examination is frequently limited. In this setting, neurophysiological examination provides valuable information about seizure detection, treatment guidance, and neurological outcome. However, to acquire reliable signals, some technical precautions need to be known. EEG is prone to artifacts, and the intensive care unit environment is rich in artifact sources (electrical devices including mechanical ventilation, dialysis, and sedative medications, and frequent noise, etc.). This review will discuss and summarize the current technical guidelines for EEG acquisition and also some practical pitfalls specific for the intensive care unit.

Diagnostic methods and treatment options for focal cortical dysplasia.

Our inability to adequately treat many patients with refractory epilepsy caused by focal cortical dysplasia (FCD), surgical inaccessibility and failures are significant clinical drawbacks. The targeting of physiologic features of epileptogenesis in FCD and colocalizing functionality has enhanced completeness of surgical resection, the main determinant of outcome. Electroencephalography (EEG)-functional magnetic resonance imaging (fMRI) and magnetoencephalography are helpful in guiding electrode implantation and surgical treatment, and high-frequency oscillations help defining the extent of the epileptogenic dysplasia. Ultra high-field MRI has a role in understanding the laminar organization of the cortex, and fluorodeoxyglucose-positron emission tomography (FDG-PET) is highly sensitive for detecting FCD in MRI-negative cases. Multimodal imaging is clinically valuable, either by improving the rate of postoperative seizure freedom or by reducing postoperative deficits. However, there is no level 1 evidence that it improves outcomes. Proof for a specific effect of antiepileptic drugs (AEDs) in FCD is lacking. Pathogenic mutations recently described in mammalian target of rapamycin (mTOR) genes in FCD have yielded important insights into novel treatment options with mTOR inhibitors, which might represent an example of personalized treatment of epilepsy based on the known mechanisms of disease. The ketogenic diet (KD) has been demonstrated to be particularly effective in children with epilepsy caused by structural abnormalities, especially FCD. It attenuates epigenetic chromatin modifications, a master regulator for gene expression and functional adaptation of the cell, thereby modifying disease progression. This could imply lasting benefit of dietary manipulation. Neurostimulation techniques have produced variable clinical outcomes in FCD. In widespread dysplasias, vagus nerve stimulation (VNS) has achieved responder rates >50%; however, the efficacy of noninvasive cranial nerve stimulation modalities such as transcutaneous VNS (tVNS) and noninvasive (nVNS) requires further study. Although review of current strategies underscores the serious shortcomings of treatment-resistant cases, initial evidence from novel approaches suggests that future success is possible.

Risk factors of postictal generalized EEG suppression in generalized convulsive seizures.

OBJECTIVE: To identify the clinical determinants of occurrence of postictal generalized EEG suppression (PGES) after generalized convulsive seizures (GCS). METHODS: We reviewed the video-EEG recordings of 417 patients included in the REPO2MSE study, a multicenter prospective cohort study of patients with drug-resistant focal epilepsy. According to ictal semiology, we classified GCS into 3 types: tonic-clonic GCS with bilateral and symmetric tonic arm extension (type 1), clonic GCS without tonic arm extension or flexion (type 2), and GCS with unilateral or asymmetric tonic arm extension or flexion (type 3). Association between PGES and person-specific or seizure-specific variables was analyzed after correction for individual effects and the varying number of seizures. RESULTS: A total of 99 GCS in 69 patients were included. Occurrence of PGES was independently associated with GCS type (p < 0.001) and lack of early administration of oxygen (p < 0.001). Odds ratio (OR) for GCS type 1 in comparison with GCS type 2 was 66.0 (95% confidence interval [CI 5.4-801.6]). In GCS type 1, risk of PGES was significantly increased when the seizure occurred during sleep (OR 5.0, 95% CI 1.2-20.9) and when oxygen was not administered early (OR 13.4, 95% CI 3.2-55.9). CONCLUSION: The risk of PGES dramatically varied as a function of GCS semiologic characteristics. Whatever the type of GCS, occurrence of PGES was prevented by early administration of oxygen.

Standardized EEG interpretation accurately predicts prognosis after cardiac arrest.

OBJECTIVE: To identify reliable predictors of outcome in comatose patients after cardiac arrest using a single routine EEG and standardized interpretation according to the terminology proposed by the American Clinical Neurophysiology Society. METHODS: In this cohort study, 4 EEG specialists, blinded to outcome, evaluated prospectively recorded EEGs in the Target Temperature Management trial (TTM trial) that randomized patients to 33°C vs 36°C. Routine EEG was performed in patients still comatose after rewarming. EEGs were classified into highly malignant (suppression, suppression with periodic discharges, burst-suppression), malignant (periodic or rhythmic patterns, pathological or nonreactive background), and benign EEG (absence of malignant features). Poor outcome was defined as best Cerebral Performance Category score 3-5 until 180 days. RESULTS: Eight TTM sites randomized 202 patients. EEGs were recorded in 103 patients at a median 77 hours after cardiac arrest; 37% had a highly malignant EEG and all had a poor outcome (specificity 100%, sensitivity 50%). Any malignant EEG feature had a low specificity to predict poor prognosis (48%) but if 2 malignant EEG features were present specificity increased to 96% (p < 0.001). Specificity and sensitivity were not significantly affected by targeted temperature or sedation. A benign EEG was found in 1% of the patients with a poor outcome. CONCLUSIONS: Highly malignant EEG after rewarming reliably predicted poor outcome in half of patients without false predictions. An isolated finding of a single malignant feature did not predict poor outcome whereas a benign EEG was highly predictive of a good outcome.

Timing of visual stimuli in V1 and V5/MT: fMRI and TMS

Time perception is used in our day-to-day activities. While we understand quite well how our brain processes vision, touch or taste, brain mechanisms subserving time perception remain largely understudied. In this study, we extended an experiment of previous master thesis run by Tatiana Kenel-Pierre. We focused on time perception in the range of milliseconds. Previous studies have demonstrated the involvement of visual areas V1 and V5/MT in the encoding of temporal information of visual stimuli. Based on these previous findings the aim of the present study was to understand if temporal information was encoded in V1 and extrastriate area V5/MT in different spatial frames i.e., head- centered versus eye-centered. To this purpose we asked eleven healthy volunteers to perform a temporal discrimination task of visual stimuli. Stimuli were presented at 4 different spatial positions (i.e., different combinations of retinotopic and spatiotopic position). While participants were engaged in this task we interfered with the activity of the right dorsal V1 and the right V5/MT with transcranial magnetic stimulation (TMS). Our preliminary results showed that TMS over both V1 and V5/MT impaired temporal discrimination of visual stimuli presented at specific spatial coordinates. But whereas TMS over V1 impaired temporal discrimination of stimuli presented in the lower left quadrant, TMS over V5/MT affected temporal discrimination of stimuli presented at the top left quadrant. Although it is always difficult to draw conclusions from preliminary results, we could tentatively say that our data seem to suggest that both V1 and V5/MT encode visual temporal information in specific spatial frames.

A Theta-Band EEG Based Index for Early Diagnosis of Alzheimer’s Disease

Despite recent advances, early diagnosis of Alzheimer’s disease (AD) from electroencephalography (EEG) remains a difficult task. In this paper, we offer an added measure through which such early diagnoses can potentially be improved. One feature that has been used for discriminative classification is changes in EEG synchrony. So far, only the decrease of synchrony in the higher frequencies has been deeply analyzed. In this paper, we investigate the increase of synchrony found in narrow frequency ranges within the θ band. This particular increase of synchrony is used with the well-known decrease of synchrony in the band to enhance detectable differences between AD patients and healthy subjects. We propose a new synchrony ratio that maximizes the differences between two populations. The ratio is tested using two different data sets, one of them containing mild cognitive impairment patients and healthy subjects, and another one, containing mild AD patients and healthy subjects. The results presented in this paper show that classification rate is improved, and the statistical difference between AD patients and healthy subjects is increased using the proposed ratio.

Theta EEG oscillatory activity and auditory change detection

The mismatch negativity is an electrophysiological marker of auditory change detection in the event-related brain potential and has been proposed to reflect an automatic comparison process between an incoming stimulus and the representation of prior items in a sequence. There is evidence for two main functional subcomponents comprising the MMN, generated by temporal and frontal brain areas, respectively. Using data obtained in an MMN paradigm, we performed time-frequency analysis to reveal the changes in oscillatory neural activity in the theta band. The results suggest that the frontal component of the MMN is brought about by an increase in theta power for the deviant trials and, possibly, by an additional contribution of theta phase alignment. By contrast, the temporal component of the MMN, best seen in recordings from mastoid electrodes, is generated by phase resetting of theta rhythm with no concomitant power modulation. Thus, frontal and temporal MMN components do not only differ with regard to their functional significance but also appear to be generated by distinct neurophysiological mechanisms.

An fMRI Study of Emotional engagement in decicion-making

It has been suggested that decisionmaking depends on sensitive feelings associatedwith cognitive processing rather than cognitiveprocessing alone. From human lesions, we knowthe medial anterior inferior-ventral prefrontalcortex processes the sensitivity associated withcognitive processing, it being essentiallyresponsible for decision making.In this fMRI (functional Magnetic ResonanceImage) study 15 subjects were analyzed usingmoral dilemmas as probes to investigate the neuralbasis for painful-emotional sensitivity associatedwith decision making. We found that a networkcomprising the posterior and anterior cingulateand the medial anterior prefrontal cortex wassignificantly and specifically activated by painfulmoral dilemmas, but not by non-painful dilemmas.These findings provide new evidence that thecingulate and medial anterior prefrontal areinvolved in processing painful emotionalsensibility, in particular, when decision makingtakes place. We speculate that decision makinghas a cognitive component processed by cognitivebrain areas and a sensitivity component processedby emotional brain areas. The structures activatedsuggest that decision making depends on painfulemotional feeling processing rather than cognitiveprocessing when painful feeling processinghappens

Mathematical modeling of level of anaesthesia from EEG measurements

Problem of modeling of anaesthesia depth level is studied in this Master Thesis. It applies analysis of EEG signals with nonlinear dynamics theory and further classification of obtained values. The main stages of this study are the following: data preprocessing; calculation of optimal embedding parameters for phase space reconstruction; obtaining reconstructed phase portraits of each EEG signal; formation of the feature set to characterise obtained phase portraits; classification of four different anaesthesia levels basing on previously estimated features. Classification was performed with: Linear and quadratic Discriminant Analysis, k Nearest Neighbours method and online clustering. In addition, this work provides overview of existing approaches to anaesthesia depth monitoring, description of basic concepts of nonlinear dynamics theory used in this Master Thesis and comparative analysis of several different classification methods.

Fenomenologinen tutkimus video-EEG potilaiden kohtauskokemuksista

Tässä fenomenologisessa tutkimuksessa kuvaillaan Video-EEG –tutkimukseen (VEEG) tulevien potilaiden kokemuksia kohtauksistaan. Tutkimusasetelmana on käytetty fenomenologiseen psykologiaan kuuluvaa Giorgin menetelmää soveltaen sitä hoitotieteen tutkimukseen. Tutkimuksen tarkoituksena oli kuvailla neurologisten kohtausoireiden vuoksi VEEG-tutkimukseen tulleiden potilaiden kokemuksia kohtauksistaan ja tunnistaa sekä kuvailla kokemukseen liittyviä tekijöitä. Tutkimuksen tavoitteena oli lisäta terveydenhoitohenkilökunnan ymmärrystä neurologisia kohtausoireita saavien ihmisten ohjaustarpeista. Materiaali kerättiin kahdeksalta potilaalta avoimilla haastatteluilla ja analysoitiin Giorgin analyysimenetelmällä. Aineistoon yhdistettiin kliinisen neurofysiologin lausunto ja muodostettiin kokemuskertomukset. Aineistosta tunnistettiin fenomenologista reduktiota käyttäen keskeiset kohtauksiin ja sairauteen liittyvät kokemukset. Käsitteiden suhdetta toisiinsa ja merkitystä sopeutumiselle analysoitiin käyttäen apuna Uncertainty in illness -mallia. Keskeisten kokemusten pohjalta toteutettiin kirjallisuushaku, jonka tuloksia reflektoitiin tämän tutkimuksen tuloksiin. Aineistosta muodostui kolme erillistä kokemuskertomusta: kertomus konkreettisista tapahtumista, kokemus hallinnan menettämisestä ja kokemus sairauden kanssa elämisesta. Keskeisiksi kokemussisällöiksi tunnistettiin kokemus terveysongelman hallinnasta, kokemus hallinnan menettämisestä, kokemus ympäristön negatiivisesta suhtautumisesta ja huoli läheisistä. Aikaisempaa tutkimusta löytyi kokemuksista terveysongelman hallinnasta ja hallinnan menetyksestä sekä ympäristön suhtautumisesta.

Fenomenologinen tutkimus video-EEG potilaiden kohtauskokemuksista

Tässä fenomenologisessa tutkimuksessa kuvaillaan Video-EEG –tutkimukseen (VEEG) tulevien potilaiden kokemuksia kohtauksistaan. Tutkimusasetelmana on käytetty fenomenologiseen psykologiaan kuuluvaa Giorgin menetelmää soveltaen sitä hoitotieteen tutkimukseen. Tutkimuksen tarkoituksena oli kuvailla neurologisten kohtausoireiden vuoksi VEEGtutkimukseen tulleiden potilaiden kokemuksia kohtauksistaan ja tunnistaa sekä kuvailla kokemukseen liittyviä tekijöitä. Tutkimuksen tavoitteena oli lisätä terveydenhoitohenkilökunnan ymmärrystä neurologisia kohtausoireita saavien ihmisten ohjaustarpeista. Materiaali kerättiin kahdeksalta potilaalta avoimilla haastatteluilla ja analysoitiin Giorgin analyysimenetelmällä. Aineistoon yhdistettiin kliinisen neurofysiologin lausunto ja muodostettiin kokemuskertomukset. Aineistosta tunnistettiin fenomenologista reduktiota käyttäen keskeiset kohtauksiin ja sairauteen liittyvät kokemukset. Käsitteiden suhdetta toisiinsa ja merkitystä sopeutumiselle analysoitiin käyttäen apuna Uncertainty in illness -mallia. Keskeisten kokemusten pohjalta toteutettiin kirjallisuushaku, jonka tuloksia reflektoitiin tämän tutkimuksen tuloksiin. Aineistosta muodostui kolme erillistä kokemuskertomusta: kertomus konkreettisista tapahtumista, kokemus hallinnan menettämisestä ja kokemus sairauden kanssa elämisestä. Keskeisiksi kokemussisällöiksi tunnistettiin kokemus terveysongelman hallinnasta, kokemus hallinnan menettämisestä, kokemus ympäristön negatiivisesta suhtautumisesta ja huoli läheisistä. Aikaisempaa tutkimusta löytyi kokemuksista terveysongelman hallinnasta ja hallinnan menetyksestä sekä ympäristön suhtautumisesta.

Effect of aerobic training on EEG alpha asymmetry and depressive symptoms in the elderly: a 1-year follow-up study

The effect of physical exercise on the treatment of depressive elderly adults has not been investigated thus far in terms of changes in cortical hemispheric activity. The objective of the present study was to identify changes in depressive symptoms, quality of life, and cortical asymmetry produced by aerobic activity. Elderly subjects with a diagnosis of major depressive disorder (DSM-IV) were included. Twenty patients (70% females, 71 ± 3 years) were divided into an exercise group (pharmacological treatment plus aerobic training) and a control group (undergoing pharmacological treatment) in a quasi-experimental design. Pharmacological treatment was maintained stable throughout the study (antidepressants and anxiolytics). Subjects were evaluated by depression scales (Beck Depression Inventory, Hamilton Depression Rating Scale, Montgomery-Asberg Depression Rating Scale) and the Short Form Health Survey-36, and electroencephalographic measurements (frontal and parietal alpha asymmetry) before and after 1 year of treatment. After 1 year, the control group showed a decrease in cortical activity on the right hemisphere (increase of alpha power), which was not observed in the exercise group. The exercise group showed a significant decrease of depressive symptoms, which was not observed in the control group. This result was also accompanied by improved treatment response and remission rate after 1 year of aerobic exercise associated with treatment. This study provides support for the effect of aerobic training on alpha activity and on depressive symptoms in elderly patients. Exercise facilitates the treatment of depressive elderly adults, leading to clinical and physical improvement and protecting against a decrease in cortical activity.

Effect of scanner acoustic background noise on strict resting-state fMRI

Functional MRI (fMRI) resting-state experiments are aimed at identifying brain networks that support basal brain function. Although most investigators consider a ‘resting-state’ fMRI experiment with no specific external stimulation, subjects are unavoidably under heavy acoustic noise produced by the equipment. In the present study, we evaluated the influence of auditory input on the resting-state networks (RSNs). Twenty-two healthy subjects were scanned using two similar echo-planar imaging sequences in the same 3T MRI scanner: a default pulse sequence and a reduced “silent” pulse sequence. Experimental sessions consisted of two consecutive 7-min runs with noise conditions (default or silent) counterbalanced across subjects. A self-organizing group independent component analysis was applied to fMRI data in order to recognize the RSNs. The insula, left middle frontal gyrus and right precentral and left inferior parietal lobules showed significant differences in the voxel-wise comparison between RSNs depending on noise condition. In the presence of low-level noise, these areas Granger-cause oscillations in RSNs with cognitive implications (dorsal attention and entorhinal), while during high noise acquisition, these connectivities are reduced or inverted. Applying low noise MR acquisitions in research may allow the detection of subtle differences of the RSNs, with implications in experimental planning for resting-state studies, data analysis, and ergonomic factors.