1
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CreveCoeur TS, Iyer RR, Goldstein HE, Delgardo MW, Hankinson TC, Erickson MA, Garg S, Skaggs DL, Andras L, Kennedy BC, Cahill PJ, Lenke LG, Angevine PD, Roye BD, Vitale MG, Mendiratta A, Anderson RCE. Timing of intraoperative neurophysiological monitoring (IONM) recovery and clinical recovery after termination of pediatric spinal deformity surgery due to loss of IONM signals. Spine J 2024:S1529-9430(24)00169-4. [PMID: 38614157 DOI: 10.1016/j.spinee.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/04/2024] [Accepted: 04/06/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND CONTEXT Intraoperative neurophysiological monitoring (IONM) is used to reduce the risk of spinal cord injury during pediatric spinal deformity surgery. Significant reduction and/or loss of IONM signals without immediate recovery may lead the surgeon to acutely abort the case. The timing of when monitorable signals return remains largely unknown. PURPOSE The goal of this study was to investigate the correlation between IONM signal loss, clinical examination, and subsequent normalization of IONM signals after aborted pediatric spinal deformity surgery to help determine when it is safe to return to the operating room. STUDY DESIGN/SETTING This is a multicenter, multidisciplinary, retrospective study of pediatric patients (< 18 years old) undergoing spinal deformity surgery whose surgery was aborted due to a significant reduction or loss of IONM potentials. PATIENT SAMPLE Sixty-six patients less than 18 years old who underwent spinal deformity surgery that was aborted due to IONM signal loss were enrolled into the study. OUTCOME MEASURES IONM data, operative reports, and clinical examinations were investigated to determine the relationship between IONM loss, clinical examination, recovery of IONM signals, and clinical outcome. METHODS Information regarding patient demographics, deformity type, clinical history, neurologic and ambulation status, operative details, IONM information (e.g., quality of loss [SSEPs, MEPs], laterality, any recovery of signals, etc.), intra-operative wake-up test, post-operative neurologic exam, post-operative imaging, and time to return to the operating were all collected. All factors were analyzed and compared with univariate and multivariate analysis using appropriate statistical analysis. RESULTS Sixty-six patients were enrolled with a median age of 13 years [IQR 11-14], and the most common sex was female (42/66, 63.6%). Most patients had idiopathic scoliosis (33/66, 50%). The most common causes of IONM loss were screw placement (27/66, 40.9%) followed by rod correction (19/66, 28.8%). All patients had either complete bilateral (39/66, 59.0%), partial bilateral (10/66, 15.2%) or unilateral (17/66, 25.8%) MEP loss leading to termination of the case. Overall, when patients were returned to the operating room two weeks postoperatively, nearly 75% (40/55) had monitorable IONM signals. Univariate analysis demonstrated that bilateral SSEP loss (p = 0.019), bilateral SSEP and MEP loss (p = 0.022) and delayed clinical neurologic recovery (p = 0.008) were significantly associated with having unmonitorable IONM signals at repeat surgery. Multivariate regression analysis demonstrated that delayed clinical neurologic recovery (> 72 hours) was significantly associated with unmonitorable IONM signals when returned to the operating room (p=0.006). All patients ultimately made a full neurologic recovery. CONCLUSIONS In children whose spinal deformity surgery was aborted due to intraoperative IONM loss, there was a strong correlation between combined intraoperative SSEP/MEP loss, the magnitude of IONM loss, the timing of clinical recovery, and the time of electrophysiological IONM recovery. The highest likelihood of having a prolonged postoperative neurological deficit and undetectable IONM signals upon return to the OR occurs with bilateral complete loss of SSEPs and MEPs.
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Affiliation(s)
- Travis S CreveCoeur
- Columbia University, Department of Neurological Surgery; Och Spine Hospital; New York City, NY.
| | - Rajiv R Iyer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/Primary Children's Hospital, Salt Lake City, UT
| | | | - Mychael W Delgardo
- Columbia University, Department of Neurological Surgery; Och Spine Hospital; New York City, NY
| | | | | | | | - David L Skaggs
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, Ca
| | - Lindsay Andras
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles; Ca
| | - Benjamin C Kennedy
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Patrick J Cahill
- Division of Orthopedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lawrence G Lenke
- Columbia University, Department of Orthopedic Surgery, New York, NY
| | - Peter D Angevine
- Columbia University, Department of Neurological Surgery; Och Spine Hospital; New York City, NY
| | - Benjamin D Roye
- Columbia University, Department of Orthopedic Surgery, New York, NY
| | - Michael G Vitale
- Columbia University, Department of Orthopedic Surgery, New York, NY
| | - Anil Mendiratta
- Department of Neurology, Columbia University Medical Center, New York, NY
| | - Richard C E Anderson
- Department of Neurosurgery, New York University, New York, New York; NYU Neurosurgery Network, Ridgewood, NJ
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2
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McIntosh JR, Joiner EF, Goldberg JL, Murray LM, Yasin B, Mendiratta A, Karceski SC, Thuet E, Modik O, Shelkov E, Lombardi JM, Sardar ZM, Lehman RA, Mandigo C, Riew KD, Harel NY, Virk MS, Carmel JB. Intraoperative electrical stimulation of the human dorsal spinal cord reveals a map of arm and hand muscle responses. J Neurophysiol 2023; 129:66-82. [PMID: 36417309 PMCID: PMC9799146 DOI: 10.1152/jn.00235.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Although epidural stimulation of the lumbar spinal cord has emerged as a powerful modality for recovery of movement, how it should be targeted to the cervical spinal cord to activate arm and hand muscles is not well understood, particularly in humans. We sought to map muscle responses to posterior epidural cervical spinal cord stimulation in humans. We hypothesized that lateral stimulation over the dorsal root entry zone would be most effective and responses would be strongest in the muscles innervated by the stimulated segment. Twenty-six people undergoing clinically indicated cervical spine surgery consented to mapping of motor responses. During surgery, stimulation was performed in midline and lateral positions at multiple exposed segments; six arm and three leg muscles were recorded on each side of the body. Across all segments and muscles tested, lateral stimulation produced stronger muscle responses than midline despite similar latency and shape of responses. Muscles innervated at a cervical segment had the largest responses from stimulation at that segment, but responses were also observed in muscles innervated at other cervical segments and in leg muscles. The cervical responses were clustered in rostral (C4-C6) and caudal (C7-T1) cervical segments. Strong responses to lateral stimulation are likely due to the proximity of stimulation to afferent axons. Small changes in response sizes to stimulation of adjacent cervical segments argue for local circuit integration, and distant muscle responses suggest activation of long propriospinal connections. This map can help guide cervical stimulation to improve arm and hand function.NEW & NOTEWORTHY A map of muscle responses to cervical epidural stimulation during clinically indicated surgery revealed strongest activation when stimulating laterally compared to midline and revealed differences to be weaker than expected across different segments. In contrast, waveform shapes and latencies were most similar when stimulating midline and laterally, indicating activation of overlapping circuitry. Thus, a map of the cervical spinal cord reveals organization and may help guide stimulation to activate arm and hand muscles strongly and selectively.
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Affiliation(s)
- James R. McIntosh
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Evan F. Joiner
- 2Department of Neurological Surgery, Columbia University, New York, New York
| | - Jacob L. Goldberg
- 4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Lynda M. Murray
- 8Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York,9James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Bushra Yasin
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Anil Mendiratta
- 3Department of Neurology, Columbia University, New York, New York
| | - Steven C. Karceski
- 5Department of Neurology, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Earl Thuet
- 6New York Presbyterian, Och Spine Hospital, New York, New York
| | - Oleg Modik
- 5Department of Neurology, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Evgeny Shelkov
- 5Department of Neurology, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Joseph M. Lombardi
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,6New York Presbyterian, Och Spine Hospital, New York, New York
| | - Zeeshan M. Sardar
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,6New York Presbyterian, Och Spine Hospital, New York, New York
| | - Ronald A. Lehman
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,6New York Presbyterian, Och Spine Hospital, New York, New York
| | - Christopher Mandigo
- 2Department of Neurological Surgery, Columbia University, New York, New York,6New York Presbyterian, Och Spine Hospital, New York, New York
| | - K. Daniel Riew
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York,6New York Presbyterian, Och Spine Hospital, New York, New York
| | - Noam Y. Harel
- 7Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York,8Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York,9James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Michael S. Virk
- 4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
| | - Jason B. Carmel
- 1Department of Orthopedic Surgery, https://ror.org/00hj8s172Columbia University, New York, New York,3Department of Neurology, Columbia University, New York, New York,4Department of Neurological Surgery, Weill Cornell Medicine-New York Presbyterian, Och Spine Hospital, New York, New York
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3
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Tobochnik S, Bateman LM, Akman CI, Anbarasan D, Bazil CW, Bell M, Choi H, Feldstein NA, Kent PF, McBrian D, McKhann GM, Mendiratta A, Pack AM, Sands TT, Sheth SA, Srinivasan S, Schevon CA. Tracking Multisite Seizure Propagation Using Ictal High-Gamma Activity. J Clin Neurophysiol 2022; 39:592-601. [PMID: 34812578 PMCID: PMC8611231 DOI: 10.1097/wnp.0000000000000833] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/28/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Spatial patterns of long-range seizure propagation in epileptic networks have not been well characterized. Here, we use ictal high-gamma activity (HGA) as a proxy of intense neuronal population firing to map the spatial evolution of seizure recruitment. METHODS Ictal HGA (80-150 Hz) was analyzed in 13 patients with 72 seizures recorded by stereotactic depth electrodes, using previously validated methods. Distinct spatial clusters of channels with the ictal high-gamma signature were identified, and seizure hubs were defined as stereotypically recruited nonoverlapping clusters. Clusters correlated with asynchronous seizure terminations to provide supportive evidence for independent seizure activity at these sites. The spatial overlap between seizure hubs and interictal ripples was compared. RESULTS Ictal HGA was detected in 71% of seizures and 10% of implanted contacts, enabling tracking of contiguous and noncontiguous seizure recruitment. Multiple seizure hubs were identified in 54% of cases, including 43% of patients thought preoperatively to have unifocal epilepsy. Noncontiguous recruitment was associated with asynchronous seizure termination (odds ratio = 19.7; p = 0.029). Interictal ripples demonstrated greater spatial overlap with ictal HGA in cases with single seizure hubs compared with those with multiple hubs (100% vs. 66% per patient; p = 0.03). CONCLUSIONS Ictal HGA may serve as a useful adjunctive biomarker to distinguish contiguous seizure spread from propagation to remote seizure sites. High-gamma sites were found to cluster in stereotyped seizure hubs rather than being broadly distributed. Multiple hubs were common even in cases that were considered unifocal.
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Affiliation(s)
- Steven Tobochnik
- Brigham and Women’s Hospital, Department of Neurology, Boston, MA
| | - Lisa M. Bateman
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Cigdem I. Akman
- Columbia University Medical Center, Division of Child Neurology, New York, NY
| | | | - Carl W. Bazil
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Michelle Bell
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Hyunmi Choi
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Neil A. Feldstein
- Columbia University Medical Center, Department of Neurological Surgery, New York, NY
| | - Paul F. Kent
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Danielle McBrian
- Columbia University Medical Center, Division of Child Neurology, New York, NY
| | - Guy M. McKhann
- Columbia University Medical Center, Department of Neurological Surgery, New York, NY
| | - Anil Mendiratta
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Alison M. Pack
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Tristan T. Sands
- Columbia University Medical Center, Division of Child Neurology, New York, NY
| | - Sameer A. Sheth
- Baylor College of Medicine, Department of Neurosurgery, Houston, TX
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4
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Michalak AJ, Mendiratta A, Eliseyev A, Ramnath B, Chung J, Rasnow J, Reid L, Salerno S, García PS, Agarwal S, Roh D, Park S, Bazil C, Claassen J. Frontotemporal EEG to guide sedation in COVID-19 related acute respiratory distress syndrome. Clin Neurophysiol 2021; 132:730-736. [PMID: 33567379 PMCID: PMC7817418 DOI: 10.1016/j.clinph.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/08/2020] [Accepted: 01/06/2021] [Indexed: 12/14/2022]
Abstract
Objective To study if limited frontotemporal electroencephalogram (EEG) can guide sedation changes in highly infectious novel coronavirus disease 2019 (COVID-19) patients receiving neuromuscular blocking agent. Methods 98 days of continuous frontotemporal EEG from 11 consecutive patients was evaluated daily by an epileptologist to recommend reduction or maintenance of the sedative level. We evaluated the need to increase sedation in the 6 h following this recommendation. Post-hoc analysis of the quantitative EEG was correlated with the level of sedation using a machine learning algorithm. Results Eleven patients were studied for a total of ninety-eight sedation days. EEG was consistent with excessive sedation on 57 (58%) and adequate sedation on 41 days (42%). Recommendations were followed by the team on 59% (N = 58; 19 to reduce and 39 to keep the sedation level). In the 6 h following reduction in sedation, increases of sedation were needed in 7 (12%). Automatized classification of EEG sedation levels reached 80% (±17%) accuracy. Conclusions Visual inspection of a limited EEG helped sedation depth guidance. In a secondary analysis, our data supported that this determination may be automated using quantitative EEG analysis. Significance Our results support the use of frontotemporal EEG for guiding sedation in patients with COVID-19.
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Affiliation(s)
- Andrew J Michalak
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Anil Mendiratta
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrey Eliseyev
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Jane Chung
- NewYork Presbyterian Hospital, New York, NY, USA
| | | | | | | | - Paul S García
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - David Roh
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Carl Bazil
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.
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5
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Waldman GJ, Thakur KT, Der Nigoghossian C, Spektor V, Mendiratta A, Bell M, Bautista AE, Lennihan L, Willey JZ, Claassen J. Multidisciplinary Guidance to Manage Comatose Patients with Severe COVID-19. Ann Neurol 2020; 88:653-655. [PMID: 32583426 PMCID: PMC7362029 DOI: 10.1002/ana.25830] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/21/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Genna J Waldman
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - Caroline Der Nigoghossian
- New York Presbyterian Hospital, New York, NY, USA.,Department of Pharmacy, Columbia University Irving Medical Center, New York, NY, USA
| | - Vadim Spektor
- New York Presbyterian Hospital, New York, NY, USA.,Department of Radiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Anil Mendiratta
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - Michelle Bell
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - Alyssa E Bautista
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - Laura Lennihan
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - Joshua Z Willey
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
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6
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Casadei CH, Carson KW, Mendiratta A, Bazil CW, Pack AM, Choi H, Srinivasan S, McKhann GM, Schevon CA, Bateman LM. All-cause mortality and SUDEP in a surgical epilepsy population. Epilepsy Behav 2020; 108:107093. [PMID: 32402704 PMCID: PMC8114948 DOI: 10.1016/j.yebeh.2020.107093] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
Epilepsy surgery is considered to reduce the risk of epilepsy-related mortality, including sudden unexpected death in epilepsy (SUDEP), though data from existing surgical series are conflicting. We retrospectively examined all-cause mortality and SUDEP in a population of 590 epilepsy surgery patients and a comparison group of 122 patients with pharmacoresistant focal epilepsy who did not undergo surgery, treated at Columbia University Medical Center between 1977 and 2014. There were 34 deaths in the surgery group, including 14 cases of SUDEP. Standardized mortality ratio (SMR) for the surgery group was 1.6, and SUDEP rate was 1.9 per 1000 patient-years. There were 13 deaths in the comparison group, including 5 cases of SUDEP. Standardized mortality ratio for the comparison group was 3.6, and SUDEP rate was 4.6 per 1000 patient-years. Both were significantly greater than in the surgery group (p < 0.05). All but one of the surgical SUDEP cases, and all of the comparison group SUDEP cases, had a history of bilateral tonic-clonic seizures (BTCS). Of postoperative SUDEP cases, one was seizure-free, and two were free of BTCS at last clinical follow-up. Time to SUDEP in the surgery group was longer than in the comparison group (10.1 vs 5.9 years, p = 0.013), with 10 of the 14 cases occurring >10 years after surgery. All-cause mortality was reduced after epilepsy surgery relative to the comparison group. There was an early benefit of surgery on the occurrence of SUDEP, which was reduced after 10 years. A larger, multicenter study is needed to further investigate the time course of postsurgical SUDEP.
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Affiliation(s)
- Camilla H. Casadei
- Department of Neurology, Columbia University Medical Center, New York, NY
| | - Kaitlin W. Carson
- Department of Neurology, Columbia University Medical Center, New York, NY
| | - Anil Mendiratta
- Department of Neurology, Columbia University Medical Center, New York, NY
| | - Carl W. Bazil
- Department of Neurology, Columbia University Medical Center, New York, NY
| | - Alison M. Pack
- Department of Neurology, Columbia University Medical Center, New York, NY
| | - Hyunmi Choi
- Department of Neurology, Columbia University Medical Center, New York, NY
| | | | - Guy M. McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY
| | | | - Lisa M. Bateman
- Department of Neurology, Columbia University Medical Center, New York, NY
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7
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Bateman LM, Mendiratta A, Liou JY, Smith EJ, Bazil CW, Choi H, McKhann GM, Pack A, Srinivasan S, Schevon CA. Postictal clinical and electroencephalographic activity following intracranially recorded bilateral tonic-clonic seizures. Epilepsia 2019; 60:74-84. [PMID: 30577077 PMCID: PMC6400590 DOI: 10.1111/epi.14621] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The dynamics of the postictal period, which may demonstrate such dramatic clinical phenomena as focal neurological deficits, prolonged coma and immobility, and even sudden death, are poorly understood. We sought to classify and characterize postictal phases of bilateral tonic-clonic seizures based on electroencephalographic (EEG) criteria and associated clinical features. METHODS We performed a detailed electroclinical evaluation of the postictal period in a series of 31 bilateral tonic-clonic seizures in 16 patients undergoing epilepsy surgery evaluations for focal pharmacoresistant epilepsy with intracranial electrodes and time-locked video. RESULTS The postictal EEG demonstrated three clearly differentiated phases as follows: attenuation, a burst-attenuation pattern, and a return to continuous background, with abrupt, synchronized transitions between phases. Postictal attenuation was common, occurring in 84% of seizures in 94% of patients in this study. There was increased power in gamma frequencies (>25 Hz) during postictal attenuation periods relative to preictal baseline in 88% of seizures demonstrating the attenuation pattern (n = 25 seizures, P < 0.002). Such increases were seen in >90% of channels in 13 seizures (52%) and <10% of channels in three seizures (12%). Postictal immobility was seen in 87% of seizures, with either a flaccid (58%) or rigid/dystonic (29%) appearance. Clinical motor manifestations, including focal dystonic posturing, automatisms, head and eye deviation, and myoclonic jerking, continued or emerged within the first minute following seizure termination in 48% of seizures, regardless of EEG appearance. SIGNIFICANCE Intracranial postictal attenuation, which may be diffuse or focal, is so common that it should be regarded as a ubiquitous feature of bilateral tonic-clonic seizures, rather than an unusual event. The prominence of high-frequency activity coupled with emerging clinical features, including rigid immobility and semiologies such as automatisms, during the postictal period supports the presence of ongoing seizure-related neuronal activity in unrecorded brain regions.
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Affiliation(s)
- Lisa M Bateman
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Anil Mendiratta
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Jyun-You Liou
- Department of Physiology and Cellular Biophysics, Columbia University Medical Center, New York, New York
| | - Elliot J Smith
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Carl W Bazil
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Hyunmi Choi
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Alison Pack
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Shraddha Srinivasan
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Catherine A Schevon
- Department of Neurology, Columbia University Medical Center, New York, New York
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8
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Choi H, Hayat MJ, Zhang R, Hirsch LJ, Bazil C, Mendiratta A, Kato K, Javed A, Legge AW, Buchsbaum R, Resor S, Heiman G. In response: Drug-resistant epilepsy in adults: outcome trajectories after failure of two medications. Epilepsia 2016; 57:1526-7. [DOI: 10.1111/epi.13487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Hyunmi Choi
- Department of Neurology; Columbia University; New York New York U.S.A
| | - Matthew J. Hayat
- School of Public Health; Georgia State University; Atlanta Georgia U.S.A
| | - Ruiqi Zhang
- Department of Applied Mathematics and Statistics; State University of New York at Stony Brook; Stony Brook New York U.S.A
| | | | - Carl Bazil
- Department of Neurology; Columbia University; New York New York U.S.A
| | - Anil Mendiratta
- Department of Neurology; Columbia University; New York New York U.S.A
| | - Kenneth Kato
- Department of Neurology; Columbia University; New York New York U.S.A
| | - Asif Javed
- Department of Neurology; Columbia University; New York New York U.S.A
| | | | - Richard Buchsbaum
- Department of Biostatistics; Mailman School of Public Health at Columbia University; New York New York U.S.A
| | | | - Gary Heiman
- Department of Genetics; The Human Genetics Institute of New Jersey; Rutgers, the State University of New Jersey; Piscataway New Jersey U.S.A
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9
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Choi H, Hayat MJ, Zhang R, Hirsch LJ, Bazil CW, Mendiratta A, Kato K, Javed A, Legge AW, Buchsbaum R, Resor S, Heiman GA. Drug-resistant epilepsy in adults: Outcome trajectories after failure of two medications. Epilepsia 2016; 57:1152-60. [PMID: 27265407 DOI: 10.1111/epi.13406] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the seizure trajectories of adults with epilepsy developing drug-resistant epilepsy (DRE) and to identify the predictors of seizure trajectory outcome. METHODS Adult patients failing two antiepileptic drugs (AEDs) due to inefficacy and starting their third AED at a tertiary epilepsy center were followed for seizure trajectory outcome during medical management. Seizure trajectories were categorized into one of four patterns: (1) course with constant seizures; (2) fluctuating course; (3) delayed attainment of seizure freedom (seizure freedom delayed for >12 months after start of the study, but patient stayed in seizure freedom); and (4) early attainment of seizure freedom (within 12 months of starting study). Multiple ordinal logistic regression models were used to estimate the association between trajectory categories and clinical factors. RESULTS Four hundred three adult patients met the eligibility criteria. Of these, 212 (53%) never achieved a seizure-free period of a year or more. The trajectories of 63 patients (16%) had a complex fluctuating trajectory, 62 (15%) had delayed onset of seizure freedom, and 66 (16%) had an early seizure freedom. Independent predictors associated with more favorable outcome trajectories were epilepsy type and length of follow-up. Specifically, compared to patients with focal epilepsy of temporal lobe, patients with focal epilepsy of occipital lobe (OR 3.80, 95% confidence interval [CI] 1.00-14.51, p = 0.04), generalized genetic (OR 3.23, 95% CI 1.88-5.57, p < 0.0001), unclear epilepsy type (OR 3.82, 95% CI 1.53-9.52, p < 0.005), and both focal and generalized epilepsy(OR 11.73, 95% CI 1.69-81.34, p = 0.01) were significantly more likely to experience a better trajectory pattern. SIGNIFICANCE Examination of patterns of seizure trajectory of patients with incident DRE showed that 31% were in continuous seizure freedom at the end of the observation period.
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Affiliation(s)
- Hyunmi Choi
- Department of Neurology, Columbia University, New York, New York, U.S.A
| | - Matthew J Hayat
- School of Public Health, Georgia State University, Atlanta, Georgia, U.S.A
| | - Ruiqi Zhang
- Department of Applied Mathematics and Statistics, State University of New York at Stony Brook, Stony Brook, New York, U.S.A
| | - Lawrence J Hirsch
- Department of Neurology, Yale University, New Haven, Connecticut, U.S.A
| | - Carl W Bazil
- Department of Neurology, Columbia University, New York, New York, U.S.A
| | - Anil Mendiratta
- Department of Neurology, Columbia University, New York, New York, U.S.A
| | - Kenneth Kato
- Department of Neurology, Columbia University, New York, New York, U.S.A
| | - Asif Javed
- Department of Neurology, Columbia University, New York, New York, U.S.A
| | - Alexander W Legge
- Department of Neurology, Columbia University, New York, New York, U.S.A
| | - Richard Buchsbaum
- Department of Biostatistics, Mailman School of Public Health at Columbia University, New York, New York, U.S.A
| | - Stanley Resor
- Department of Biostatistics, Mailman School of Public Health at Columbia University, New York, New York, U.S.A
| | - Gary A Heiman
- Department of Genetics, The Human Genetics Institute of New Jersey, Rutgers, The State University of New Jersey, Piscataway, New Jersey, U.S.A
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10
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Gilliam FG, Mendiratta A, Pack AM, Bazil CW. Epilepsy and common comorbidities: improving the outpatient epilepsy encounter. Epileptic Disord 2005; 7 Suppl 1:S27-33. [PMID: 16120491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Epilepsy is a chronic disorder that has been associated with other specific health problems. Evidence from recent clinical and basic investigations indicates that aspects of cerebral dysfunction associated with a lowered seizure threshold may also predispose toward other disorders such as depression, cognitive impairment, sleep disorders, and migraine. Similarly, certain types of brain injury may also increase the risk of adverse antiepileptic drug (AED) effects. For example, a history of febrile seizures is associated with a three fold increase in the occurrence of negative psychiatric effects of two newer AEDs. Poor fitness and obesity are also reported at higher rates in epilepsy. Some comorbid conditions in epilepsy, such a depression and anxiety, may have a greater influence on subjective health status than does seizure rate. Management strategies employed in the outpatient clinic to maximize overall health outcomes should include screening and treatment for the commonly coexistent conditions in persons with epilepsy.
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Affiliation(s)
- Frank G Gilliam
- Department of Neurology, Neurological Institute, Columbia University, New York, NY 10032, USA.
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11
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Abstract
Electroencephalography (EEG) continues to be the most important diagnostic tool in the management of patients with epilepsy. In particular, the high specificity of interictal epileptiform discharges makes scalp EEG a valuable tool in the evaluation of patients with a history of seizures or seizure-like episodes. Advances in technology, most notably the development of digital video-EEG, have significantly expanded the utility of EEG. In addition to the routine EEG, long-term monitoring studies including video-EEG, ambulatory EEG, and continuous EEG monitoring play important roles in various aspects of the diagnosis and treatment of epilepsy. Recent developments in computerized seizure detection and prediction algorithms, particularly those utilizing intracranial EEG electrodes, hold promise for future development of novel treatment strategies.
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Affiliation(s)
- Anil Mendiratta
- Department of Neurology, College of Physicians and Surgeons of Columbia University, 710 West 168th Street, Box 213, New York, NY 10032, USA.
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