Quantitative artifact reduction and pharmacologic paralysis improve detection of EEG epileptiform activity in critically ill patients

OBJECTIVE

Epileptiform activity is common in critically ill patients, but movement-related artifacts-including electromyography (EMG) and myoclonus-can obscure EEG, limiting detection of epileptiform activity. We sought to determine the ability of pharmacologic paralysis and quantitative artifact reduction (AR) to improve epileptiform discharge detection.

METHODS

Retrospective analysis of patients who underwent continuous EEG monitoring with pharmacologic paralysis. Four reviewers read each patient's EEG pre- and post- both paralysis and AR, and indicated the presence of epileptiform discharges. We compared the interrater reliability (IRR) of identifying discharges at baseline, post-AR, and post-paralysis, and compared the performance of AR and paralysis according to artifact type.

RESULTS

IRR of identifying epileptiform discharges at baseline was slight (N = 30; κ = 0.10) with a trend toward increase post-AR (κ = 0.26, p = 0.053) and a significant increase post-paralysis (κ = 0.51, p = 0.001). AR was as effective as paralysis at improving IRR of identifying discharges in those with high EMG artifact (N = 15; post-AR κ = 0.63, p = 0.009; post-paralysis κ = 0.62, p = 0.006) but not with primarily myoclonus artifact (N = 15).

CONCLUSIONS

Paralysis improves detection of epileptiform activity in critically ill patients when movement-related artifact obscures EEG features. AR improves detection as much as paralysis when EMG artifact is high, but is ineffective when the primary source of artifact is myoclonus.

SIGNIFICANCE

In the appropriate setting, both AR and paralysis facilitate identification of epileptiform activity in critically ill patients.

Using Generalized Polyspike Train to Predict Drug-Resistant Idiopathic Generalized Epilepsy

INTRODUCTION

The authors tested the hypothesis that the EEG feature generalized polyspike train (GPT) is associated with drug-resistant idiopathic generalized epilepsy (IGE).

METHODS

The authors conducted a single-center case-control study of patients with IGE who had outpatient EEGs performed between 2016 and 2020. The authors classified patients as drug-resistant or drug-responsive based on clinical review and in a masked manner reviewed EEG data for the presence and timing of GPT (a burst of generalized rhythmic spikes lasting less than 1 second) and other EEG features. A relationship between GPT and drug resistance was tested before and after controlling for EEG duration. The EEG duration needed to observe GPT was also calculated.

RESULTS

One hundred three patients were included (70% drug-responsive and 30% drug-resistant patients). Generalized polyspike train was more prevalent in drug-resistant IGE (odds ratio, 3.8; 95% confidence interval, 1.3-11.4; P = 0.02). This finding persisted when controlling for EEG duration both with stratification and with survival analysis. A median of 6.5 hours (interquartile range, 0.5-12.7 hours) of EEG recording was required to capture the first occurrence of GPT.

CONCLUSIONS

The findings support the hypothesis that GPT is associated with drug-resistant IGE. Prolonged EEG recording is required to identify this feature. Thus, >24-hour EEG recording early in the evaluation of patients with IGE may facilitate prognostication.

Prognostic value of EEG asymmetries for development of drug-resistance in drug-naïve patients with genetic generalized epilepsies

OBJECTIVE

Previous studies based solely on visual EEG analysis reported equivocal results regarding an association of pharmaco-resistance with EEG asymmetries in genetic generalized epilepsies (GGE). We addressed this issue by applying both visual and quantitative methods to the pretreatment EEG of GGE patients.

METHODS

Socio-demographic/disease characteristics and response to treatment/discontinuation trial for these patients were recorded at 6months and at last follow up. The first EEG was retrospectively, blindly, and visually assessed for focal slowing, focal discharges and also quantitatively analyzed for amplitude or latency asymmetries of generalized discharges. Association between these variables and development of drug-resistance was evaluated.

RESULTS

Out of 51 subjects, 40% had some type of EEG asymmetry by visual, 37% by quantitative and 54% by combined analysis. Drug-resistance was identified in 52% of patients after 6months and in 24% at the end of the follow up period (∼4.2years). 27% of patients underwent a discontinuation trial; 43% unsuccessfully. There was no association between baseline EEG asymmetries of any type and refractoriness to medical therapy, regardless of analytical method used.

CONCLUSIONS

In a carefully selected cohort of medication-naïve GGE patients, visual and quantitative asymmetries in the first EEG were not associated with the development of pharmaco-resistance.

SIGNIFICANCE

These findings do not provide support for utilization of EEG asymmetries as a prognostic tool in GGE.

Foramen ovale electrodes in the evaluation of epilepsy surgery: conventional and unconventional uses

Foramen ovale (FO) electrodes have been used in the evaluation of epilepsy surgery for more than 25 years. Their traditional application was in patients with mesial temporal lobe epilepsy. Due in part to advances in neuroimaging, their use has declined. We describe our cumulative experience with FO electrodes and use examples to illustrate a range of indications for FO recordings that extend beyond their conventional utility for mesial temporal lobe cases. We also summarize the pros and cons of FO electrodes implantation and attempt to reestablish their utility in presurgical evaluation.

Temporal characteristics of neurons in the central mesencephalic reticular formation of head unrestrained monkeys

The accompanying paper demonstrated two distinct types of central mesencephalic reticular formation (cMRF) neuron that discharged before or after the gaze movement: pre-saccadic or post-saccadic. The movement fields of pre-saccadic neurons were most closely associated with gaze displacement. The movement fields of post-saccadic neurons were most closely associated with head displacement. Here we examine the relationships of the discharge patterns of these cMRF neurons with the temporal aspects of gaze or head movement. For pre-saccadic cMRF neurons with monotonically open movement fields, we demonstrate that burst duration correlated closely with gaze duration. In addition, the peak discharge of the majority of pre-saccadic neurons was closely correlated with peak gaze velocity. In contrast, discharge parameters of post-saccadic neurons were best correlated with the time of peak head velocity. However, the duration and peak discharge of post-saccadic discharge was only weakly related to the duration and peak velocity of head movement. As a result, for the majority of post-saccadic neurons the discharge waveform poorly correlated with the dynamics of head movement. We suggest that the discharge characteristics of pre-saccadic cMRF neurons with monotonically open movement fields are similar to that of direction long-lead burst neurons found previously in the paramedian portion of the pontine reticular formation (PPRF; Hepp and Henn 1983). In light of their anatomic connections with the PPRF, these pre-saccadic neurons could form a parallel pathway that participates in the transformation from the spatial coding of gaze in the superior colliculus (SC) to the temporal coding displayed by excitatory burst neurons of the PPRF. In contrast, closed and non-monotonically open movement field pre-saccadic neurons could play a critical role in feedback to the SC. The current data do not support a role for post-saccadic cMRF neurons in the direct control of head movements, but suggest that they may serve a feedback or reafference function, providing a signal of current head amplitude to upstream regions involved in head control.

Spatial characteristics of neurons in the central mesencephalic reticular formation (cMRF) of head-unrestrained monkeys

Prior studies of the central portion of the mesencephalic reticular formation (cMRF) have shown that in head-restrained monkeys, neurons discharge prior to saccades. Here, we provide a systematic analysis of the patterns of activity in cMRF neurons during head unrestrained gaze shifts. Two types of cMRF neurons were found: presaccadic neurons began to discharge before the onset of gaze movements, while postsaccadic neurons began to discharge after gaze shift onset and typically after the end of the gaze shift. Presaccadic neuronal responses were well correlated with gaze movements, while the discharge of postsaccadic neurons was more closely associated with head movements. The activity of presaccadic neurons was organized into gaze movement fields, while the activity of postsaccadic neurons was better organized into movement fields associated with head displacement. We found that cMRF neurons displayed both open and closed movement field responses. Neurons with closed movement fields discharged before a specific set of gaze (presaccadic) or head (postsaccadic) movement amplitudes and directions and had a clear distal boundary. Neurons with open movement fields discharged for gaze or head movements of a specific direction and also for movement amplitudes up to the limit of measurement (70 degrees). A subset of open movement field neurons displayed an increased discharge with increased gaze shift amplitudes, similar to pontine burst neurons, and were called monotonically increasing open movement field neurons. In contrast, neurons with non-monotonically open movement fields demonstrated activity for all gaze shift amplitudes, but their activity reached a plateau or declined gradually for gaze shifts beyond specific amplitudes. We suggest that presaccadic neurons with open movement fields participate in a descending pathway providing gaze signals to medium-lead burst neurons in the paramedian pontine reticular formation, while presaccadic closed movement field neurons may participate in feedback to the superior colliculus. The previously unrecognized group of postsaccadic cMRF neurons may provide signals of head position or velocity to the thalamus, cerebellum, or spinal cord.