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Gélisse P, Tatum WO, Crespel A, Kaplan PW. Stimulus-induced arousal with transient electroencephalographic improvement distinguishes nonictal from ictal generalized periodic discharges. Epilepsia 2024. [PMID: 38624097 DOI: 10.1111/epi.17987] [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] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 04/17/2024]
Abstract
In the case of suspicion of nonconvulsive status epilepticus (NCSE), reactivity on electroencephalograms (EEGs) can provide valuable diagnostic information. Reactivity refers to responses to auditory or somatosensory stimulation, with changes in amplitude and frequency of background activity. Because of self-perpetuating processes and the failure of self-terminating mechanisms, status epilepticus is unlikely to cease when patients spontaneously move, and it cannot typically be stopped by external stimulation (i.e., auditory and tactile stimuli). The defining EEG characteristic of absence status epilepticus is the presence of bilateral, synchronous, symmetric, rhythmic paroxysmal activity that shows little or no reactivity to sensory stimulation. On the other hand, in metabolic/toxic or multifactorial encephalopathies, triphasic waves (TWs) are influenced by the level of vigilance. TWs may be transiently abolished when patients increase their level of alertness from a drowsy/lethargic state to a state of wakefulness. This reactivity is only observed when patients can be aroused by a somatosensory or auditory stimulus. This reactivity tends to disappear with increasing severity of the disease and in comatose patients. In patients without preexisting developmental and epileptic encephalopathy, this pattern of stimulus-induced wakefulness with transient improvement of the EEG is a major criterion in determining that the EEG patterns are not ictal. This criterion of reactivity on EEGs, beyond the classical clinical/EEG criteria of NCSE (Salzburg criteria), should now be systematically added.
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Affiliation(s)
- Philippe Gélisse
- Epilepsy Unit, Hôpital Gui de Chauliac, Montpellier, France
- Unité de Recherche sur les Comportements et Mouvements Anormaux, Institut National de la Santé Et de la Recherche Médicale, Montpellier, France
| | - William O Tatum
- Department of Neurology, Mayo Clinic College of Medicine and Health Sciences, Jacksonville, Florida, USA
| | - Arielle Crespel
- Epilepsy Unit, Hôpital Gui de Chauliac, Montpellier, France
- Unité de Recherche sur les Comportements et Mouvements Anormaux, Institut National de la Santé Et de la Recherche Médicale, Montpellier, France
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
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Freund BE, Husari KS, Kaplan PW. Danger in plain sight: determining who is at highest risk for cefepime induced neurotoxicity and its associated morbidity and mortality. Acta Neurol Belg 2024:10.1007/s13760-024-02546-5. [PMID: 38589733 DOI: 10.1007/s13760-024-02546-5] [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] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/23/2024] [Indexed: 04/10/2024]
Abstract
Cefepime is a fourth-generation cephalosporin that is widely used to treat sepsis but is associated with a potentially dangerous neurotoxicity syndrome, cefepime-induced neurotoxicity (CIN). As a result, patients treated with cefepime may be at higher risk for morbidity, including seizures, and mortality. Though the recent ACORN trial concluded that cefepime does not increase the risk of mortality, most of these patients were not critically ill or elderly, two of the most at risk populations for CIN. Further, diagnosis may be difficult in the critical care setting as patients may have multiple reasons for encephalopathy. Therefore, this population in particular should be studied and monitored closely for CIN. Importantly, there are not well defined diagnostic criteria for CIN to guide evaluation and management. Defining the risk factors for CIN and using laboratory and EEG to help support the clinical diagnosis could be helpful in early recognition of CIN to help institute treatment and to rule out seizures. In this mini review, we highlight risk factors for CIN, discuss the possible value of EEG, and propose a diagnostic and management approach in the evaluation and management of CIN.
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Affiliation(s)
- Brin E Freund
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.
| | - Khalil S Husari
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Morris H, Kaplan PW, Kane N. Electroencephalography in encephalopathy and encephalitis. Pract Neurol 2024; 24:2-10. [PMID: 38050141 DOI: 10.1136/pn-2023-003798] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2023] [Indexed: 12/06/2023]
Abstract
Electroencephalography (EEG) is a useful adjunct to clinical neurological examination, particularly as it may detect subtle or subclinical disturbance of cerebral function and it allows monitoring of cerebral activity over time. Continuous EEG combined with quantitative analysis and machine learning may help identify changes in real time, before the emergence of clinical signs and response to interventions. EEG is rarely pathognomonic in encephalopathy/encephalitis but when interpreted correctly and within the clinical context, certain phenotypes may indicate a specific pathophysiology (eg, lateralised periodic discharges in HSV-1, generalised periodic discharges in sporadic Creutzfeldt-Jakob disease, and extreme delta brushes in anti-n-methyl-D-aspartate receptor autoimmune encephalitis). EEG is included in some specialist guidelines for disease assessment, monitoring and prognostication (ie, hepatic, cancer immunotherapy, viral, prion, autoimmune encephalitis and hypoxic ischaemic encephalopathy). EEG is invaluable for confirming or excluding non-convulsive seizures or status epilepticus, particularly in critically ill patients, and in understanding new concepts such as epileptic encephalopathy and the ictal-interictal continuum.
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Affiliation(s)
- Hollie Morris
- Grey Walter Dept of Clinical Neurophysiology, North Bristol NHS Trust, Bristol, UK
| | - Peter W Kaplan
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Nick Kane
- Grey Walter Dept of Clinical Neurophysiology, North Bristol NHS Trust, Westbury on Trym, UK
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Gélisse P, Tatum WO, Crespel A, Jallon P, Kaplan PW. Determining ICU EEG periodic patterns and why it matters. J Neurol 2023; 270:4744-4752. [PMID: 37393201 PMCID: PMC10511623 DOI: 10.1007/s00415-023-11835-7] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 07/03/2023]
Abstract
Historically, periodic EEG patterns were described as any pattern with stereotyped paroxysmal complexes occurring at regular intervals, i.e., the period (T). T is the sum of the duration of the waveform (t1) and, eventually, the duration of the interval between two consecutive waves (t2). The American Clinical Neurophysiology Society introduced the concept of a clearly discernible inter-discharge interval between consecutive waveforms (i.e., t2). As this definition was not applied to what have previously been termed triphasic waves and in some cases of lateralized periodic discharges, we propose reconsideration of terminology that includes historical use of definitions. This will allow the development and usage of the concept for periodic EEG patterns as any runs of stereotyped paroxysmal waveforms separated by nearly identical intervals and prolonged repetitive complexes on the EEG. Prolonged expression means EEG is recorded for a sufficient period of time to prove that the pattern is repetitive, thus resulting in a monomorphic/monotonous pattern. More important than the inter-discharge interval (t2), periodic EEG patterns occur at time regular intervals (T). As a result, periodic EEG activity should be considered along a continuum and not the opposite of rhythmic EEG activity where no interval activity exists between consecutive waveforms.
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Affiliation(s)
- Philippe Gélisse
- Epilepsy Unit, Hôpital Gui de Chauliac, 80 Avenue Fliche, 34295, Montpellier Cedex 05, France.
- Research Unit (URCMA: Unité de Recherche sur les Comportements et Mouvements Anormaux), INSERM, U661, Montpellier, France.
| | - William O Tatum
- Department of Neurology, Mayo Clinic College of Medicine and Health Sciences, Jacksonville, FL, USA
| | - Arielle Crespel
- Epilepsy Unit, Hôpital Gui de Chauliac, 80 Avenue Fliche, 34295, Montpellier Cedex 05, France
- Research Unit (URCMA: Unité de Recherche sur les Comportements et Mouvements Anormaux), INSERM, U661, Montpellier, France
| | - Pierre Jallon
- University Medical Center, Ho Chi Minh City, Vietnam
| | - Peter W Kaplan
- Epilepsy and EEG Unit, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Leitinger M, Gaspard N, Hirsch LJ, Beniczky S, Kaplan PW, Husari K, Trinka E. Diagnosing nonconvulsive status epilepticus: Defining electroencephalographic and clinical response to diagnostic intravenous antiseizure medication trials. Epilepsia 2023; 64:2351-2360. [PMID: 37350392 DOI: 10.1111/epi.17694] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/17/2023] [Accepted: 06/20/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE The Salzburg criteria for nonconvulsive status epilepticus (NCSE) and the American Clinical Neurophysiology Society (ACNS) Standardized Critical Care EEG Terminology 2021 include a diagnostic trial with intravenous (IV) antiseizure medications (ASMs) to assess electroencephalographic (EEG) and clinical response as a diagnostic criterion for definite NCSE and possible NCSE. However, how to perform this diagnostic test and assessing the EEG and clinical responses have not been operationally defined. METHODS We performed a Delphi process involving six experts to standardize the diagnostic administration of IV ASM and propose operational criteria for EEG and clinical response. RESULTS Either benzodiazepines (BZDs) or non-BZD ASMs can be used as first choice for a diagnostic IV ASM trial. However, non-BZDs should be considered in patients who already have impaired alertness or are at risk of respiratory depression. Levetiracetam, valproate, lacosamide, brivaracetam, or (if the only feasible drug) fosphenytoin or phenobarbital were deemed appropriate for a diagnostic IV trial. The starting dose should be approximately two thirds to three quarters of the full loading dose recommended for treatment of status epilepticus, with an additional smaller dose if needed. ASMs should be administered during EEG recording under supervision. A monitoring time of at least 15 min is recommended. If there is no response, a second trial with another non-BDZ or BDZs may be considered. A positive EEG response is defined as the resolution of the ictal-interictal continuum pattern for at least three times the longest previously observed spontaneous interval of resolution (if any), but minimum of one continuous minute. For a clinical response, physicians should use a standardized examination before and after IV ASM administration. We suggest a definite time-locked improvement in a focal deficit or at least one-step improvement on a new dedicated one-domain 10-level NCSE response scale. SIGNIFICANCE The proposed standardized approach of a diagnostic IV ASM trial further refines the ACNS and Salzburg diagnostic criteria for NCSE.
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Affiliation(s)
- Markus Leitinger
- Department of Neurology, member of European Reference Network EpiCARE, Center for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Neuroscience Institute, Center for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Nicolas Gaspard
- Hôpital Universitaire de Bruxelles-Hôpital Erasme, Brussels, Belgium
- Université Libre de Bruxelles, Brussels, Belgium
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund, Denmark
- Department of Clinical Neurophysiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Khalil Husari
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Eugen Trinka
- Department of Neurology, member of European Reference Network EpiCARE, Center for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Neuroscience Institute, Center for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics, and Technology, Hall in Tyrol, Austria
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Freund B, Chen B, Kaplan PW, Johnson EL. Managing Antiseizure Medications in Pregnancy: Is Earlier and More Frequent Monitoring Better? Neurol Clin Pract 2023; 13:e200169. [PMID: 37223248 PMCID: PMC10202371 DOI: 10.1212/cpj.0000000000200169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/28/2023] [Indexed: 05/25/2023]
Abstract
Background and Objective Medication management in pregnant women with epilepsy (PWWE) poses challenges, and understanding the effects of metabolic changes on antiseizure medications (ASMs) is important in planning care for PWWE. The possible teratogenic effects and risks of poorly controlled seizures have to be weighed. There are data in the literature on clinical management of ASMs including the effects of drug levels on seizures and factors that predict seizure frequency, but timing and frequency of monitoring and dose adjustment paradigms have not been well studied. Methods This retrospective study was approved by the Institutional Review Board at Johns Hopkins University. We retrospectively identified adult PWWE evaluated during pregnancy at the Johns Hopkins Bayview Medical Center epilepsy clinic, between January 1, 2007, and January 1, 2021. We reviewed charts for information regarding demographics, medical and epilepsy history, medications, serum drug levels, and dosing paradigms. We assessed risk factors for breakthrough seizures with a focus on frequency and timing of laboratory testing. We calculated the dose-normalized concentration (DNC) for analysis with levetiracetam and lamotrigine, assessing changes in DNC over time by half trimesters, and analyzed DNC and effects on seizures in pregnancy. We also compared preemptive vs clinically based lamotrigine dose adjustments in managing epilepsy in pregnancy. Results A total of 45 pregnancies in 39 patients were included in this study, 8 generalized, 28 focal epilepsy, and 3 unclassified. 31 PWWE (36 pregnancies) were on lamotrigine and/or levetiracetam, and 14 of these pregnancies experienced breakthrough seizures, 77% in the first trimester. Seizures led to the diagnosis of pregnancy in 5 patients. The DNC for levetiracetam decreased significantly compared with prepregnancy levels by the second half of the first trimester and demonstrated variable but frequently significant or near significant reduction throughout pregnancy. DNC for lamotrigine decreased significantly in the first half of the first trimester and remained significant throughout pregnancy. Age of mother at conception, week of first ASM serum level and number of levels obtained during pregnancy, and epilepsy type were not associated with breakthrough/increase in seizures. The history of drug resistance (p = 0.038) was associated with a higher odds of seizures. In those on lamotrigine, preemptive dose adjustments demonstrated similar results regarding seizure control when compared with clinical-based or laboratory-based dose management (p = 0.531). Discussion This study demonstrates that frequency and timing of ASM level monitoring may not affect overall seizure outcomes during pregnancy in those on lamotrigine or levetiracetam. Furthermore, one can consider preemptive dose adjustments or a laboratory-based/clinical-based approach in managing lamotrigine as both seem safe and feasible. However, in those with drug-resistant epilepsy before pregnancy, earlier and closer monitoring is warranted given the risk of seizures early during pregnancy. Larger prospective studies are needed to confirm these results.
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Affiliation(s)
- Brin Freund
- Department of Neurology (BF, BC), Mayo Clinic, Jacksonville, FL; and Department of Neurology (PWK, ELJ), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Baibing Chen
- Department of Neurology (BF, BC), Mayo Clinic, Jacksonville, FL; and Department of Neurology (PWK, ELJ), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Peter W Kaplan
- Department of Neurology (BF, BC), Mayo Clinic, Jacksonville, FL; and Department of Neurology (PWK, ELJ), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Emily L Johnson
- Department of Neurology (BF, BC), Mayo Clinic, Jacksonville, FL; and Department of Neurology (PWK, ELJ), Johns Hopkins Bayview Medical Center, Baltimore, MD
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Chaudhry N, Bergey GK, Kaplan PW, Johnson EL. Life Stressors During Pregnancy in Women With Epilepsy: Results From the Pregnancy Risk Assessment Monitoring System. Neurology 2023; 100:e2424-e2431. [PMID: 37072226 PMCID: PMC10264049 DOI: 10.1212/wnl.0000000000207274] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 02/23/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To compare specific life stressors and domestic abuse that pregnant women and others with epilepsy (WWE) experience compared with pregnant women and others without epilepsy (WWoE). METHODS The Pregnancy Risk Assessment Monitoring System (PRAMS) is an annual weighted survey of randomly sampled postpartum women administered by the Centers for Disease Control and Prevention. We used data from the PRAMS from 2012 to 2020 in 13 states to assess the life stressors reported by WWE compared with WWoE. We adjusted the data for maternal age, race, ethnicity, marital status, education, and socioeconomic status (SES; using income, Women, Infants, and Children program [WIC], and Medicaid use). We also examined reported abuse in WWE compared with WWoE. RESULTS This study included data from 64,951 postpartum women, representing 4,072,189 women through weighted sampling. Of these, 1,140 reported having a diagnosis of epilepsy in the 3 months before their pregnancies (representing 81,021 WWE). WWE experienced a higher number of stressors compared with WWoE. WWE were more likely to have experienced 9 of the 14 stressors asked in the PRAMS questionnaire: severe illness of a close family member, separation or divorce, homelessness, loss of a partner's job, cut in work hours or pay, arguing more than usual with their partner, serving jail time, substance abuse problem in a close contact, and death of a close contact. After adjusting for demographics (age, race, and SES), epilepsy was still associated with a higher number of stressors in pregnant women. Other factors associated with stressors were younger age, Indigenous or mixed race, non-Hispanic ethnicity, lower income, and WIC or Medicaid use. Those who were married were less likely to report stressors. WWE were also more likely to report abuse before or during their pregnancies. DISCUSSION Although managing stress is important in both epilepsy and pregnancy, WWE experience more stressors than do WWoE. After adjusting for maternal age, race, and SES, this increase in stressors persisted. Women who were younger, with lower income, on WIC or Medicaid, or not married were also more likely to experience life stressors. Alarmingly, reported abuse was also higher in WWE compared with WWoE. Attention from clinicians and support services for WWE are needed to optimize good pregnancy outcomes.
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Affiliation(s)
- Naveed Chaudhry
- From the Department of Neurology (N.C.), University of Colorado School of Medicine, Denver; and Department of Neurology (G.K.B., P.W.K., E.L.J.), Johns Hopkins School of Medicine, Baltimore, MD.
| | - Gregory K Bergey
- From the Department of Neurology (N.C.), University of Colorado School of Medicine, Denver; and Department of Neurology (G.K.B., P.W.K., E.L.J.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Peter W Kaplan
- From the Department of Neurology (N.C.), University of Colorado School of Medicine, Denver; and Department of Neurology (G.K.B., P.W.K., E.L.J.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Emily L Johnson
- From the Department of Neurology (N.C.), University of Colorado School of Medicine, Denver; and Department of Neurology (G.K.B., P.W.K., E.L.J.), Johns Hopkins School of Medicine, Baltimore, MD
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Jing J, Ge W, Struck AF, Fernandes MB, Hong S, An S, Fatima S, Herlopian A, Karakis I, Halford JJ, Ng MC, Johnson EL, Appavu BL, Sarkis RA, Osman G, Kaplan PW, Dhakar MB, Jayagopal LA, Sheikh Z, Taraschenko O, Schmitt S, Haider HA, Kim JA, Swisher CB, Gaspard N, Cervenka MC, Rodriguez Ruiz AA, Lee JW, Tabaeizadeh M, Gilmore EJ, Nordstrom K, Yoo JY, Holmes MG, Herman ST, Williams JA, Pathmanathan J, Nascimento FA, Fan Z, Nasiri S, Shafi MM, Cash SS, Hoch DB, Cole AJ, Rosenthal ES, Zafar SF, Sun J, Westover MB. Interrater Reliability of Expert Electroencephalographers Identifying Seizures and Rhythmic and Periodic Patterns in EEGs. Neurology 2023; 100:e1737-e1749. [PMID: 36460472 PMCID: PMC10136018 DOI: 10.1212/wnl.0000000000201670] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 10/25/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The validity of brain monitoring using electroencephalography (EEG), particularly to guide care in patients with acute or critical illness, requires that experts can reliably identify seizures and other potentially harmful rhythmic and periodic brain activity, collectively referred to as "ictal-interictal-injury continuum" (IIIC). Previous interrater reliability (IRR) studies are limited by small samples and selection bias. This study was conducted to assess the reliability of experts in identifying IIIC. METHODS This prospective analysis included 30 experts with subspecialty clinical neurophysiology training from 18 institutions. Experts independently scored varying numbers of ten-second EEG segments as "seizure (SZ)," "lateralized periodic discharges (LPDs)," "generalized periodic discharges (GPDs)," "lateralized rhythmic delta activity (LRDA)," "generalized rhythmic delta activity (GRDA)," or "other." EEGs were performed for clinical indications at Massachusetts General Hospital between 2006 and 2020. Primary outcome measures were pairwise IRR (average percent agreement [PA] between pairs of experts) and majority IRR (average PA with group consensus) for each class and beyond chance agreement (κ). Secondary outcomes were calibration of expert scoring to group consensus, and latent trait analysis to investigate contributions of bias and noise to scoring variability. RESULTS Among 2,711 EEGs, 49% were from women, and the median (IQR) age was 55 (41) years. In total, experts scored 50,697 EEG segments; the median [range] number scored by each expert was 6,287.5 [1,002, 45,267]. Overall pairwise IRR was moderate (PA 52%, κ 42%), and majority IRR was substantial (PA 65%, κ 61%). Noise-bias analysis demonstrated that a single underlying receiver operating curve can account for most variation in experts' false-positive vs true-positive characteristics (median [range] of variance explained ([Formula: see text]): 95 [93, 98]%) and for most variation in experts' precision vs sensitivity characteristics ([Formula: see text]: 75 [59, 89]%). Thus, variation between experts is mostly attributable not to differences in expertise but rather to variation in decision thresholds. DISCUSSION Our results provide precise estimates of expert reliability from a large and diverse sample and a parsimonious theory to explain the origin of disagreements between experts. The results also establish a standard for how well an automated IIIC classifier must perform to match experts. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that an independent expert review reliably identifies ictal-interictal injury continuum patterns on EEG compared with expert consensus.
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Affiliation(s)
- Jin Jing
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Wendong Ge
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Aaron F Struck
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Marta Bento Fernandes
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Shenda Hong
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sungtae An
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Safoora Fatima
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Aline Herlopian
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Ioannis Karakis
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jonathan J Halford
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Marcus C Ng
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Emily L Johnson
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Brian L Appavu
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Rani A Sarkis
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Gamaleldin Osman
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Peter W Kaplan
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Monica B Dhakar
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Lakshman Arcot Jayagopal
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Zubeda Sheikh
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Olga Taraschenko
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sarah Schmitt
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Hiba A Haider
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jennifer A Kim
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Christa B Swisher
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Nicolas Gaspard
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Mackenzie C Cervenka
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Andres A Rodriguez Ruiz
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jong Woo Lee
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Mohammad Tabaeizadeh
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Emily J Gilmore
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Kristy Nordstrom
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Ji Yeoun Yoo
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Manisha G Holmes
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Susan T Herman
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jennifer A Williams
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jay Pathmanathan
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Fábio A Nascimento
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Ziwei Fan
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Samaneh Nasiri
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Mouhsin M Shafi
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sydney S Cash
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Daniel B Hoch
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Andrew J Cole
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Eric S Rosenthal
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Sahar F Zafar
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - Jimeng Sun
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL
| | - M Brandon Westover
- From the Massachusetts General Hospital/Harvard Medical School Department of Neurology (J.J., W.G., M.B.F., S.S.C., A.J.C., D.B.H., E.S.R., S.F.Z., M.B.W.), MA; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), MA; University of Wisconsin-Madison Department of Neurology (A.F.S., S.F.); William S. Middleton Memorial Veterans Hospital Madison (A.F.S.), WI; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; Georgia Institute of Technology (S.A.), College of Computing, Atlanta, GA; Yale University-Yale New Haven Hospital (A.H.), CT; Emory University School of Medicine (I.K.), GA; Medical University of South Carolina (J.J.H.), SC; University of Manitoba (M.C.N.), Canada; Johns Hopkins School of Medicine (E.L.J.), MD; University of Arizona College of Medicine (B.L.A.), AZ; Brigham and Women's Hospital (R.A.S.), MA; Mayo Clinic-Rochester (G.O.), MN; Warren Alpert School of Medicine of Brown University (M.B.D.), Providence, RI; University of Nebraska Medical Center (L.A.J.), NE; West Virginia University Hospitals (Z.S.), WV; University of Chicago (H.A.H.), Chicago, IL; Atrium Health (C.B.S.), NC; Université Libre de Bruxelles - Hôpital Erasme (N.G.), Belgium; Icahn School of Medicine, Mount Sinai (J.Y.Y.), NY; New York University (NYU) Grossman School of Medicine (M.G.H.), NY; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), PA; Beth Israel Deaconess Medical Center/Harvard Medical School (M.M.S.), MA; and University of Illinois at Urbana-Champaign (J.S.), College of Computing, Champaign, IL.
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Jing J, Ge W, Hong S, Fernandes MB, Lin Z, Yang C, An S, Struck AF, Herlopian A, Karakis I, Halford JJ, Ng MC, Johnson EL, Appavu BL, Sarkis RA, Osman G, Kaplan PW, Dhakar MB, Arcot Jayagopal L, Sheikh Z, Taraschenko O, Schmitt S, Haider HA, Kim JA, Swisher CB, Gaspard N, Cervenka MC, Rodriguez Ruiz AA, Lee JW, Tabaeizadeh M, Gilmore EJ, Nordstrom K, Yoo JY, Holmes MG, Herman ST, Williams JA, Pathmanathan J, Nascimento FA, Fan Z, Nasiri S, Shafi MM, Cash SS, Hoch DB, Cole AJ, Rosenthal ES, Zafar SF, Sun J, Westover MB. Development of Expert-Level Classification of Seizures and Rhythmic and Periodic Patterns During EEG Interpretation. Neurology 2023; 100:e1750-e1762. [PMID: 36878708 PMCID: PMC10136013 DOI: 10.1212/wnl.0000000000207127] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 01/12/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Seizures (SZs) and other SZ-like patterns of brain activity can harm the brain and contribute to in-hospital death, particularly when prolonged. However, experts qualified to interpret EEG data are scarce. Prior attempts to automate this task have been limited by small or inadequately labeled samples and have not convincingly demonstrated generalizable expert-level performance. There exists a critical unmet need for an automated method to classify SZs and other SZ-like events with expert-level reliability. This study was conducted to develop and validate a computer algorithm that matches the reliability and accuracy of experts in identifying SZs and SZ-like events, known as "ictal-interictal-injury continuum" (IIIC) patterns on EEG, including SZs, lateralized and generalized periodic discharges (LPD, GPD), and lateralized and generalized rhythmic delta activity (LRDA, GRDA), and in differentiating these patterns from non-IIIC patterns. METHODS We used 6,095 scalp EEGs from 2,711 patients with and without IIIC events to train a deep neural network, SPaRCNet, to perform IIIC event classification. Independent training and test data sets were generated from 50,697 EEG segments, independently annotated by 20 fellowship-trained neurophysiologists. We assessed whether SPaRCNet performs at or above the sensitivity, specificity, precision, and calibration of fellowship-trained neurophysiologists for identifying IIIC events. Statistical performance was assessed by the calibration index and by the percentage of experts whose operating points were below the model's receiver operating characteristic curves (ROCs) and precision recall curves (PRCs) for the 6 pattern classes. RESULTS SPaRCNet matches or exceeds most experts in classifying IIIC events based on both calibration and discrimination metrics. For SZ, LPD, GPD, LRDA, GRDA, and "other" classes, SPaRCNet exceeds the following percentages of 20 experts-ROC: 45%, 20%, 50%, 75%, 55%, and 40%; PRC: 50%, 35%, 50%, 90%, 70%, and 45%; and calibration: 95%, 100%, 95%, 100%, 100%, and 80%, respectively. DISCUSSION SPaRCNet is the first algorithm to match expert performance in detecting SZs and other SZ-like events in a representative sample of EEGs. With further development, SPaRCNet may thus be a valuable tool for an expedited review of EEGs. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that among patients with epilepsy or critical illness undergoing EEG monitoring, SPaRCNet can differentiate (IIIC) patterns from non-IIIC events and expert neurophysiologists.
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Affiliation(s)
- Jin Jing
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Wendong Ge
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Shenda Hong
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Marta Bento Fernandes
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Zhen Lin
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Chaoqi Yang
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Sungtae An
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Aaron F Struck
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Aline Herlopian
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Ioannis Karakis
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jonathan J Halford
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Marcus C Ng
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Emily L Johnson
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Brian L Appavu
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Rani A Sarkis
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Gamaleldin Osman
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Peter W Kaplan
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Monica B Dhakar
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Lakshman Arcot Jayagopal
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Zubeda Sheikh
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Olga Taraschenko
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Sarah Schmitt
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Hiba A Haider
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jennifer A Kim
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Christa B Swisher
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Nicolas Gaspard
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Mackenzie C Cervenka
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Andres A Rodriguez Ruiz
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jong Woo Lee
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Mohammad Tabaeizadeh
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Emily J Gilmore
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Kristy Nordstrom
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Ji Yeoun Yoo
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Manisha G Holmes
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Susan T Herman
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jennifer A Williams
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jay Pathmanathan
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Fábio A Nascimento
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Ziwei Fan
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Samaneh Nasiri
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Mouhsin M Shafi
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Sydney S Cash
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Daniel B Hoch
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Andrew J Cole
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Eric S Rosenthal
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Sahar F Zafar
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - Jimeng Sun
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA
| | - M Brandon Westover
- From the Department of Neurology (J.J., W.G., M.B.F., M.T., K.N., F.A.N., Z.F., S.N., S.S.C., D.B.H., A.J.C., E.S.R., S.F.Z., M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Massachusetts General Hospital Clinical Data Animation Center (CDAC) (J.J., W.G., M.B.F., M.T., F.A.N., Z.F., S.N., S.S.C., D.B.H., S.F.Z., M.B.W.), Boston; National Institute of Health Data Science (S.H.), Peking University, Beijing, China; College of Computing (Z.L., C.Y., J.S.), University of Illinois at Urbana-Champaign; College of Computing (S.A.), Georgia Institute of Technology, Atlanta; Department of Neurology (A.F.S.), University of Wisconsin-Madison; William S. Middleton Memorial Veterans Hospital (A.F.S.), Madison, WI; Yale New Haven Hospital (A.H., J.A.K., E.J.G.), Yale University, CT; Emory University School of Medicine (I.K., A.A.R.R.), Atlanta, GA; Medical University of South Carolina (J.J.H., S.S.), Charleston; University of Manitoba (M.C.N.), Winnipeg, Canada; Johns Hopkins School of Medicine (E.L.J., P.W.K., M.C.C.), Baltimore, MD; University of Arizona College of Medicine (B.L.A.), Phoenix; Brigham and Women's Hospital (R.A.S., J.W.L.), Boston, MA; Mayo Clinic (G.O.), Rochester, MN; Warren Alpert School of Medicine (M.B.D.), Brown University, Providence, RI; University of Nebraska Medical Center (L.A.J., O.T.), Omaha; West Virginia University Hospitals (Z.S.), Morgantown; University of Chicago (H.A.H.), IL; Atrium Health (C.B.S.), Charlotte, NC; Hôpital Erasme (N.G.), Université Libre de Bruxelles, Belgium; Icahn School of Medicine (J.Y.Y.), Mount Sinai, NY; NYU Grossman School of Medicine (M.G.H.), New York; Barrow Neurological Institute (S.T.H.), Phoenix, AZ; Mater Misericordiae University Hospital (J.A.W.), Dublin, Ireland; University of Pennsylvania (J.P.), Philadelphia; and Beth Israel Deaconess Medical Center (M.M.S.), Harvard Medical School, Boston, MA.
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Freund BE, Brigham T, Salman S, Kaplan PW, Tatum WO. From Alpha to Zeta: A Systematic Review of Zeta Waves. J Clin Neurophysiol 2023; 40:2-8. [PMID: 36604788 DOI: 10.1097/wnp.0000000000000972] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Electroencephalogram is used for prognostication and diagnosis in critically ill patients and is vital in developing clinical management algorithms. Unique waveforms on EEG may distinguish neurological disorders and define a potential for seizures. To better characterize zeta waves, we sought to define their electroclinical spectrum. METHODS We performed a systematic review using MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Review [through Ovid], Scopus, Science Citation Index Expanded and Emerging Sources Citation Index [through the Web of Science], and Epistemonikos. Grey literature resources were searched. RESULTS Five hundred thirty-seven articles were identified. After excluding duplicates and reviewing titles, abstracts, and bodies and bibliographies of articles, four studies reported 64 cases describing data from patients with zeta waves, with a prevalence of 3 to 4%. Various and often incomplete clinical, neuroimaging, and EEG data were available. 57 patients (89.1%) had a focal cerebral lesion concordant with the location of zeta waves on EEG. 26 patients (40.6%) had clinical seizures, all but one being focal onset. Thirteen patients (20%) had epileptiform activity on EEG. Typically, zeta waves were located in the frontal head regions, often with generalized, frontal, predominant, rhythmic delta activity and associated with focal EEG suppression. CONCLUSIONS Zeta waves frequently represent an underlying focal structural lesion. Their presence suggests a heightened risk for seizures. The small number of retrospective cases series in the literature reporting zeta waves might be an underrepresentation. We suggest a need for prospective studies of cEEG in critically ill patients to determine their clinical significance.
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Affiliation(s)
- Brin E Freund
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, U.S.A
| | - Tara Brigham
- Mayo Clinic Libraries, Mayo Clinic, Jacksonville, Florida, U.S.A.; and
| | - Saif Salman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, U.S.A
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
| | - William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, U.S.A
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Fernández-Torre JL, Kaplan PW. Response to: Multiple Myeloma-Induced Hyperammonemic Encephalopathy: Another Important Potential Cause of Triphasic Waves. J Clin Neurophysiol 2022; 39:648. [PMID: 36219229 DOI: 10.1097/wnp.0000000000000960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- José L Fernández-Torre
- Marqués de Valdecilla University Hospital, Santander, Spain
- Department of Clinical Neurophysiology, Biomedical Research Institute (IDIVAL), Santander, Spain; and
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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Gélisse P, Kaplan PW. How to evaluate and assess the epileptogenic/seizure potential of periodic discharges along the ictal-interictal continuum? Z Epileptol 2022. [DOI: 10.1007/s10309-022-00526-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractThe ictal–interictal continuum (IIC) is a concept used for those particular EEG patterns that do not meet the strict criteria for status epilepticus but may be associated with neuronal injury. The aim of this article is to review equivocal periodic patterns and to discuss their clinical significance along the IIC. The risk of seizures increases when the frequency of periodic discharges exceeds 2 Hz and when the pattern has features of superimposed rhythmic, sharp, or fast activity (plus modifier). Lateralized periodic discharges (LPDs) are one of the best examples of the IIC. Criteria have been proposed for identifying patterns along the IIC that we called “peri-ictal” LPDs. There is ongoing debate about when to treat patients with these EEG patterns along this spectrum. The term IIC is only an EEG description, and does not in itself reflect a clinical diagnosis, hence management is based on EEG alone. The decision to intensify treatment is based on the combination of EEG, the underlying etiology, the level of consciousness, comorbidities, imaging, and other surrogates of “damage.”
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Tatum WO, Rubboli G, Kaplan PW, Mirsattari SM, Radhakrishnan K, Gloss D, Caboclo LO, Drislane FW, Koutroumanidis M, Schomer DL, Kasteleijn-Nolst Trenite D, Cook M, Beniczky S. Corrigendum to "Clinical utility of EEG in diagnosing and monitoring epilepsy in adults" [Clin. Neurophysiol. 129 (2018) 1056-1082]. Clin Neurophysiol 2022; 141:160. [PMID: 35786363 DOI: 10.1016/j.clinph.2022.06.002] [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: 11/03/2022]
Affiliation(s)
- W O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.
| | - G Rubboli
- Department of Neurology, Danish Epilepsy Center, Filadelphia, University of Copenhagen, Copenhagen, Diannalund, Denmark
| | - P W Kaplan
- Johns-Hopkins University, Baltimore, MD, USA
| | - S M Mirsattari
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - K Radhakrishnan
- Department of Neurology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - D Gloss
- CAMC Department of Neurology, Charleston, WV, USA
| | - L O Caboclo
- Department of Neurology, Hospital Israelita Albert Einstein, Saõ Paolo, Brazil
| | - F W Drislane
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | - M Koutroumanidis
- Department of Neurology, Guys and St Thomas' NHS Trust, King's College, London, United Kingdom
| | - D L Schomer
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | - D Kasteleijn-Nolst Trenite
- Brain Center, University Medical Center, Utrecht, The Netherlands; Department of Pediatrics, Sapienza University, Rome, Italy
| | - Mark Cook
- Department of Neurology, University of Melbourne, Melbourne, Australia
| | - S Beniczky
- Department of Clinical Neurophysiology, Aarhus University Hospital, Denmark
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De Stefano P, Kaplan PW, Sutter R. Not all rhythmicities and periodicities in coma EEG are fatal - when simplification becomes dangerous. Epilepsia 2022; 63:2164-2167. [PMID: 35665924 PMCID: PMC9544942 DOI: 10.1111/epi.17319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/29/2022] [Accepted: 06/03/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Pia De Stefano
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland.,EEG and Epilepsy Unit, Neurology Unit, Department of Clinical Neurosciences and Faculty of Medicine of Geneva, University Hospital of Geneva, Geneva, Switzerland
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Raoul Sutter
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland.,Division of Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland.,Medical faculty, University of Basel, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland
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15
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Harid NM, Jing J, Hogan J, Nascimento FA, Ouyang A, Zheng WL, Ge W, Zafar SF, Kim JA, Lam AD, Herlopian A, Maus D, Karakis I, Ng M, Hong S, Zhu Y, Kaplan PW, Cash S, Shafi M, Martz G, Halford JJ, Westover MB. Measuring expertise in identifying interictal epileptiform discharges. Epileptic Disord 2022; 24:496-506. [PMID: 35770748 PMCID: PMC9340812 DOI: 10.1684/epd.2021.1409] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Interictal epileptiform discharges on EEG are integral to diagnosing epilepsy. However, EEGs are interpreted by readers with and without specialty training, and there is no accepted method to assess skill in interpretation. We aimed to develop a test to quantify IED recognition skills. METHODS A total of 13,262 candidate IEDs were selected from EEGs and scored by eight fellowship-trained reviewers to establish a gold standard. An online test was developed to assess how well readers with different training levels could distinguish candidate waveforms. Sensitivity, false positive rate and calibration were calculated for each reader. A simple mathematical model was developed to estimate each reader's skill and threshold in identifying an IED, and to develop receiver operating characteristics curves for each reader. We investigated the number of IEDs needed to measure skill level with acceptable precision. RESULTS Twenty-nine raters completed the test; nine experts, seven experienced non-experts and thirteen novices. Median calibration errors for experts, experienced non-experts and novices were -0.056, 0.012, 0.046; median sensitivities were 0.800, 0.811, 0.715; and median false positive rates were 0.177, 0.272, 0.396, respectively. The number of test questions needed to measure those scores was 549. Our analysis identified that novices had a higher noise level (uncertainty) compared to experienced non-experts and experts. Using calculated noise and threshold levels, receiver operating curves were created, showing increasing median area under the curve from novices (0.735), to experienced non-experts (0.852) and experts (0.891). SIGNIFICANCE Expert and non-expert readers can be distinguished based on ability to identify IEDs. This type of assessment could also be used to identify and correct differences in thresholds in identifying IEDs.
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Affiliation(s)
- Nitish M. Harid
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Jin Jing
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Jacob Hogan
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | | | - An Ouyang
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Wei-Long Zheng
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Wendong Ge
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Sahar F. Zafar
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Jennifer A. Kim
- Department of Neurology, Yale School of Medicine, New Haven CT, USA
| | - Alice D. Lam
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Aline Herlopian
- Department of Neurology, Yale School of Medicine, New Haven CT, USA
| | - Douglas Maus
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta GA, USA
| | - Marcus Ng
- Department of Neurology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shenda Hong
- National Institute of Health Data Science, Peking University, Beijing China
| | - Yu Zhu
- Xuanwu Hospital, Capital Medical University, Beijing China
| | - Peter W. Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Bayview Medical Center, Baltimore, MD, USA
| | - Sydney Cash
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Mouhsin Shafi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Gabriel Martz
- Department of Neurology, Hartford HealthCare Medical Group at Hartford Hospital, CT, USA
| | - Jonathan J. Halford
- Department of Neurology, Medical University of South Carolina, Charleston SC, USA
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16
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Ismail FY, Saleem GT, Kaplan PW. Neurophysiological and Neuroimaging Modalities in Acute and Subacute Disorders of Consciousness. J Clin Neurophysiol 2022; 39:2-3. [PMID: 34474429 DOI: 10.1097/wnp.0000000000000816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Fatima Y Ismail
- Department of Pediatrics, United Arab Emirates University, Al Ain, United Arab Emirates
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Ghazala T Saleem
- State University of New York at Buffalo, Buffalo, New York, U.S.A
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
- EEG and Epilepsy, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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17
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Nascimento FA, Jing J, Beniczky S, Benbadis SR, Gavvala JR, Yacubian EMT, Wiebe S, Rampp S, van Putten MJAM, Tripathi M, Cook MJ, Kaplan PW, Tatum WO, Trinka E, Cole AJ, Westover MB. One EEG, one read - A manifesto towards reducing interrater variability among experts. Clin Neurophysiol 2021; 133:68-70. [PMID: 34814017 DOI: 10.1016/j.clinph.2021.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Fábio A Nascimento
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Jin Jing
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund and Aarhus University Hospital, Aarhus, Denmark
| | - Selim R Benbadis
- Department of Neurology, University of South Florida and Tampa General Hospital, Tampa, FL, USA
| | - Jay R Gavvala
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Elza M T Yacubian
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Stefan Rampp
- Department of Neurosurgery, University Hospital Erlangen, Germany
| | - Michel J A M van Putten
- Department of Clinical Neurophysiology, University of Twente and Medisch Spectrum Twente, Enschede, the Netherlands
| | - Manjari Tripathi
- Department of Neurology, AII India Institute of Medical Sciences, New Delhi, India
| | - Mark J Cook
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | | | - Eugen Trinka
- Department of Neurology and Neuroscience Institute, Christian Doppler University Hospital, Center for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Andrew J Cole
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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18
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Fernández-Torre JL, Kaplan PW. Atypical or Typical Triphasic Waves-Is There a Difference? A Review. J Clin Neurophysiol 2021; 38:384-398. [PMID: 34155183 DOI: 10.1097/wnp.0000000000000731] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY The entity of triphasic waves (TWs) and TW encephalopathy has derived from the subjective art of EEG interpretation. Indeed, there are few if any guidelines regarding many different aspects of TWs. The authors seek to shed light on the nature and the diagnostic characteristics of various types of TWs, differentiating "typical" from "atypical" forms. The authors conclude that morphologies in the form of bursts of well-formed, smoothly contoured, negative-positive-negative, bilateral, symmetrical and synchronous, regular, reactive, periodic or rhythmic, 1.5 to 2.0 Hz, fronto-central, triphasic complexes with fronto-occipital lag meet the criteria for typical TWs and are highly suggestive of toxic-metabolic encephalopathies. These are most frequently hepatic, uremic, or sepsis-associated encephalopathies with multi-organ failure. In such cases, atypical TWs (frontopolar or parieto-occipital maximum, negative-positive or negative-positive-negative, asymmetric and asynchronous, unreactive, irregular, multifocal, continuous with spatiotemporal evolution, sharper and without fronto-occipital/occipito-frontal lag, or triphasic delta waves) are rarely seen. Atypical TWs are encountered in Angelman syndrome, toxic encephalopathies, hyperthyroidism/hypothyroidism, Hashimoto encephalopathy, nonconvulsive status epilepticus, dementia, sepsis-associated encephalopathy, cerebrovascular disorders, and certain boundary syndromes. Investigations describing TWs with uncommon etiologies revealed few with typical TWs, suggesting that the term "TWs" has been overused in the past. Triphasic waves arise from the interaction of multiple factors including toxic, metabolic, infectious, and structural disorders that affect circuits between thalamus and cortex. The patient's metabolic status, presence of potentially neurotoxic drugs, cerebral atrophy, white matter disease, dementia, or seizures help differentiate typical from typical TWs. Future studies will determine whether this dichotomy is heuristically and clinically helpful.
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Affiliation(s)
- José L Fernández-Torre
- Clinical Neurophysiology Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
- Biomedical Research Institute (IDIVAL), Santander, Cantabria, Spain; and
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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19
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Freund B, Kotchetkov IS, Kaplan PW. White Matter Disease-The True Source of Triphasic Waves? J Clin Neurophysiol 2021; 38:359-361. [PMID: 34155178 DOI: 10.1097/wnp.0000000000000745] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Triphasic waves are EEG phenomena typically seen in patients with acute encephalopathy and have importance in diagnosis and prognosis in these cases. The underlying metabolic disturbances associated with their incidence have been described previously, but neuroimaging characteristics are not well delineated. There are a few small studies that define neuroimaging results in patients with triphasic waves. This review highlights the most common neuroimaging findings in these patients, including subcortical white matter disease, which itself may be a risk factor for triphasic waves.
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Affiliation(s)
- Brin Freund
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A. ; and
| | - Ivan S Kotchetkov
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, U.S.A
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A. ; and
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20
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Kaplan PW, Gélisse P, Sutter R. An EEG Voyage in Search of Triphasic Waves-The Sirens and Corsairs on the Encephalopathy/EEG Horizon: A Survey of Triphasic Waves. J Clin Neurophysiol 2021; 38:348-358. [PMID: 34155177 DOI: 10.1097/wnp.0000000000000725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
SUMMARY Generalized periodic discharges with triphasic wave (TW) morphology, long referred to as TWs, are typical of many toxic, metabolic, infectious, and cerebral structural problems, often in concert. Identifying TWs has been challenging for the electroencephalographer and clinician, as has been their cause, significance, prognosis, and treatment. This review highlights the many different patterns of TWs with commentary on their various causes and etiologies, characteristics, different morbidities, differentiation from nonconvulsive status epilepticus, and their prognosis. The articles in this Journal of Clinical Neurophysiology special issue on TWs will review the many challenges the clinician face when TWs are sighted.
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Affiliation(s)
- Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
| | - Philippe Gélisse
- Department of Neurology, Epilepsy Unit Montpellier, Montpellier, France
| | - Raoul Sutter
- Intensive Care Units and Department of Neurology, University Hospital Basel, Basel, Switzerland; and
- University of Basel, Basel, Switzerland
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21
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Kaplan PW. Editorial on Triphasic Waves. J Clin Neurophysiol 2021; 38:347. [PMID: 34155182 DOI: 10.1097/wnp.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Peter W Kaplan
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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22
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Abstract
SUMMARY Triphasic waves are a fascinating and mysterious EEG feature. We now have to accept that, at times, epileptiform discharges may have a blunted "triphasic morphology," and that there may be great difficulty in distinguishing between these often similar forms. The aim of this review was to describe the evolution in our understanding of triphasic waves that has occurred regarding the pathophysiology of triphasic waves, their most frequent causes, and the diagnostic difficulties involved in interpretation and differentiation from nonconvulsive status epilepticus.
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Affiliation(s)
- José L Fernández-Torre
- Clinical Neurophysiology Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
- Biomedical Research Institute (IDIVAL), Santander, Cantabria, Spain; and
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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Abstract
PURPOSE Triphasic waves (TWs) have been observed in the EEG recorded in patients with various types of encephalopathy, yet their genesis and significance is still debated. The aim of this study was to elucidate the localization of the cortical generators of TWs using EEG source imaging. METHODS In 20 consecutive patients who had encephalopathy with TWs, EEG source imaging of the first negative and the positive phases of the TW was performed. Three different approaches were used: equivalent current dipoles, a distributed source model, and a recently described spatial filtration method for visualizing EEG in source space. RESULTS Equivalent current dipole models failed to provide valid solutions. The distributed source model and the spatial filtration method suggested that TWs were generated by large, bilateral cortical networks, invariably involving the anterior frontal and the temporo-polar areas. CONCLUSIONS Source imaging localized TWs to anterior frontal and temporo-frontal structures. Involvement of these regions is consistent with the typical pathophysiological changes of altered consciousness and cognitive changes observed in patients with TW encephalopathy.
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Affiliation(s)
- Mustafa Aykut Kural
- Departments of Clinical Neurophysiology and
- Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Martin Fabricius
- Department of Clinical Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Christensen
- Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A.; and
| | - Sándor Beniczky
- Departments of Clinical Neurophysiology and
- Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark
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Husari KS, Kaplan PW. Are Triphasic Waves Different From Generalized Spike-Wave Discharges? J Clin Neurophysiol 2021; 38:e20-e23. [PMID: 34009844 DOI: 10.1097/wnp.0000000000000845] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Generalized periodic discharges with triphasic morphology were previously referred to as triphasic waves but have now been subsumed into the ACNS classification as generalized periodic discharges. Although triphasic waves and generalized spike-wave complexes may resemble each other and hence may be incorrectly identified in comatose critically ill patients, many authors believe that there are different entities, with definable morphologic and clinical differences attributable to each waveform. The occurrence of both patterns in the same patient is extremely rare with only a single prior case report. Here the authors report a patient with typical triphasic waves and generalized spike-wave complexes and highlight the morphologic and EEG differences between the two patterns. The occurrence of both waveforms in the same EEG recording supports the notion of different cerebral generators and pathways, further differentiating rather than merging these morphologies.
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Affiliation(s)
- Khalil S Husari
- Department of Neurology, Johns Hopkins University; Baltimore, Maryland, U.S.A.; and
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University; Baltimore, Maryland, U.S.A.; and
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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25
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Gelisse P, Crespel A, Luigi Gigli G, Kaplan PW. Stimulus-Induced Rhythmic or Periodic Intermittent Discharges (SIRPIDs) in patients with triphasic waves and Creutzfeldt-Jakob disease. Clin Neurophysiol 2021; 132:1757-1769. [PMID: 34130242 DOI: 10.1016/j.clinph.2021.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 11/20/2022]
Abstract
Since the term Stimulus-Induced Rhythmic, Periodic, or Ictal Discharges (SIRPIDs) was introduced into the vocabulary of electrophysiologists/neurologists, there has been an ongoing debate about its significance, as well as its correlation with outcomes. SIRPIDs are frequently seen in patients who are critically ill from various causes. The literature reflects the findings of triphasic morphology, with the generalized periodic discharge (GPD) classification in many patients with SIRPIDs: toxic/metabolic encephalopathies, septic, and hypoxemic/hypercapnic encephalopathies, but also sharp periodic complexes in Creutzfeldt-Jakob disease and advanced Alzheimer's disease. In these settings, GPDs disappear when patients fall asleep and reappear when patients spontaneously wake up, or are awoken by an external stimulus, or sometimes because of a respiratory event, with the possibility of the appearance of GPDs with a cyclic alternating pattern. SIRPIDs may be seen as a transitional pattern between sleep and waking states, corresponding to a postarousal/awakening phenomenon. As SIRPIDs are a transient phenomenon and can usually be recorded repeatedly with each stimulation, the word "Ictal" could be replaced by "Intermittent": Stimulus-Induced Rhythmic or Periodic Intermittent Discharges. However, considering that SIRPIDs may be "potentially ictal" or on an "ictal-interictal continuum" in some situations, the "plus" modifier may be added: SIRPIDs-plus.
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Affiliation(s)
- Philippe Gelisse
- Epilepsy Unit, Hôpital Gui de Chauliac, Montpellier, France; Research Unit (URCMA: Unité de Recherche sur les Comportements et Mouvements Anormaux), INSERM, U661, Montpellier F-34000, France.
| | - Arielle Crespel
- Epilepsy Unit, Hôpital Gui de Chauliac, Montpellier, France; Research Unit (URCMA: Unité de Recherche sur les Comportements et Mouvements Anormaux), INSERM, U661, Montpellier F-34000, France
| | - Gian Luigi Gigli
- Clinical Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy; DMIF, University of Udine, Udine, Italy
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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26
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Gelisse P, Crespel A, Genton P, Jallon P, Kaplan PW. Lateralized Periodic Discharges: Which patterns are interictal, ictal, or peri-ictal? Clin Neurophysiol 2021; 132:1593-1603. [PMID: 34034086 DOI: 10.1016/j.clinph.2021.04.003] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/03/2021] [Accepted: 04/16/2021] [Indexed: 11/26/2022]
Abstract
There is an ongoing debate if Lateralized Periodic Discharges (LPDs) represent an interictal pattern reflecting non-specific but irritative brain injury, or conversely, is an ictal pattern. The challenge is: how to correctly manage these patients? Between this apparent dichotomous distinction, there is a pattern lying along the interictal-ictal continuum (IIC) that we may call "peri-ictal". Peri-ictal means that LPDs are temporally associated with epileptic seizures (although not necessarily in the same recording). Their recognition should lead to careful EEG monitoring and longer periods of video-EEG to detect seizure activity (clinical and/or subclinical seizures). In order to distinguish which kind of LPDs should be considered as representing interictal/irritative brain injury versus ictal/peri-ictal LPDs, a set of criteria, with both clinical/neuroimaging and EEG, is proposed. Among them, the dichotomy LPDs-proper versus LPDs-plus should be retained. Spiky or sharp LPDs followed by associated slow after-waves or periods of flattening giving rise to a triphasic morphology should be included in the definition of LPDs-plus. We propose defining a particular subtype of LPDs-plus that we call "LPDs-max". The LPDs-max pattern corresponds to an ictal pattern, and therefore, a focal non-convulsive status epilepticus, sometimes associated with subtle motor signs and epileptic seizures. LPDs-max include periodic polyspike-wave activity and/or focal burst-suppression-like patterns. LPDs-max have a posterior predominance over the temporo-parieto-occipital regions and are refractory to antiseizure drugs. Interpretations of EEGs in critically ill patients require a global clinical approach, not limited to the EEG patterns. The clinical context and results of neuroimaging play key roles.
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Affiliation(s)
- Philippe Gelisse
- Epilepsy Unit, Hôpital Gui de Chauliac, Montpellier, France; Research Unit (URCMA: Unité de Recherche sur les Comportements et Mouvements Anormaux), INSERM, U661, Montpellier F-34000, France.
| | - Arielle Crespel
- Epilepsy Unit, Hôpital Gui de Chauliac, Montpellier, France; Research Unit (URCMA: Unité de Recherche sur les Comportements et Mouvements Anormaux), INSERM, U661, Montpellier F-34000, France
| | - Pierre Genton
- Neurology Department, Hôpital Saint Charles, 13100 Aix en Provence, France
| | - Pierre Jallon
- University Medical Center, Ho Chi Minh City, Viet Nam
| | - Peter W Kaplan
- Epilepsy and EEG Unit, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Ge W, Jing J, An S, Herlopian A, Ng M, Struck AF, Appavu B, Johnson EL, Osman G, Haider HA, Karakis I, Kim JA, Halford JJ, Dhakar MB, Sarkis RA, Swisher CB, Schmitt S, Lee JW, Tabaeizadeh M, Rodriguez A, Gaspard N, Gilmore E, Herman ST, Kaplan PW, Pathmanathan J, Hong S, Rosenthal ES, Zafar S, Sun J, Brandon Westover M. Deep active learning for Interictal Ictal Injury Continuum EEG patterns. J Neurosci Methods 2021; 351:108966. [PMID: 33131680 PMCID: PMC8135050 DOI: 10.1016/j.jneumeth.2020.108966] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 07/14/2020] [Revised: 09/16/2020] [Accepted: 10/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Seizures and seizure-like electroencephalography (EEG) patterns, collectively referred to as "ictal interictal injury continuum" (IIIC) patterns, are commonly encountered in critically ill patients. Automated detection is important for patient care and to enable research. However, training accurate detectors requires a large labeled dataset. Active Learning (AL) may help select informative examples to label, but the optimal AL approach remains unclear. METHODS We assembled >200,000 h of EEG from 1,454 hospitalized patients. From these, we collected 9,808 labeled and 120,000 unlabeled 10-second EEG segments. Labels included 6 IIIC patterns. In each AL iteration, a Dense-Net Convolutional Neural Network (CNN) learned vector representations for EEG segments using available labels, which were used to create a 2D embedding map. Nearest-neighbor label spreading within the embedding map was used to create additional pseudo-labeled data. A second Dense-Net was trained using real- and pseudo-labels. We evaluated several strategies for selecting candidate points for experts to label next. Finally, we compared two methods for class balancing within queries: standard balanced-based querying (SBBQ), and high confidence spread-based balanced querying (HCSBBQ). RESULTS Our results show: 1) Label spreading increased convergence speed for AL. 2) All query criteria produced similar results to random sampling. 3) HCSBBQ query balancing performed best. Using label spreading and HCSBBQ query balancing, we were able to train models approaching expert-level performance across all pattern categories after obtaining ∼7000 expert labels. CONCLUSION Our results provide guidance regarding the use of AL to efficiently label large EEG datasets in critically ill patients.
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Affiliation(s)
- Wendong Ge
- Massachusetts General Hospital, Department of Neurology, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jin Jing
- Massachusetts General Hospital, Department of Neurology, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Sungtae An
- Georgia Institute of Technology, College of Computing, Atlanta, GA, Georgia
| | | | | | - Aaron F Struck
- University of Wisconsin Madison Department of Neurology, United States
| | - Brian Appavu
- University of Arizona College of Medicine, Phoenix, United States
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Nicolas Gaspard
- Université Libre de Bruxelles, Hôpital Erasme and Yale University, Belgium
| | - Emily Gilmore
- Yale University, Yale New Haven Hospital, United States
| | - Susan T Herman
- Barrow Neurological Institute, Phoenix, AZ, United States
| | | | | | - Shenda Hong
- Georgia Institute of Technology, College of Computing, Atlanta, GA, Georgia
| | - Eric S Rosenthal
- Massachusetts General Hospital, Department of Neurology, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Sahar Zafar
- Massachusetts General Hospital, Department of Neurology, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jimeng Sun
- University of Illinois at Urbana-Champaign, College of Computing, Champaign, IL, United States
| | - M Brandon Westover
- Massachusetts General Hospital, Department of Neurology, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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28
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Hirsch LJ, Fong MW, Leitinger M, LaRoche SM, Beniczky S, Abend NS, Lee JW, Wusthoff CJ, Hahn CD, Westover MB, Gerard EE, Herman ST, Haider HA, Osman G, Rodriguez-Ruiz A, Maciel CB, Gilmore EJ, Fernandez A, Rosenthal ES, Claassen J, Husain AM, Yoo JY, So EL, Kaplan PW, Nuwer MR, van Putten M, Sutter R, Drislane FW, Trinka E, Gaspard N. American Clinical Neurophysiology Society's Standardized Critical Care EEG Terminology: 2021 Version. J Clin Neurophysiol 2021; 38:1-29. [PMID: 33475321 PMCID: PMC8135051 DOI: 10.1097/wnp.0000000000000806] [Citation(s) in RCA: 308] [Impact Index Per Article: 102.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Lawrence J. Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael W.K. Fong
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Suzette M. LaRoche
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Sandor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund and Aarhus University Hospital, Aarhus, Denmark
| | - Nicholas S. Abend
- Departments of Neurology and Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jong Woo Lee
- Brigham and Women’s Hospital, Boston, Massachusetts, U.S.A
| | | | - Cecil D. Hahn
- Division of Neurology, The Hospital for Sick Children, and Department of Pediatrics, University of Toronto, Toronto, Canada
| | | | - Elizabeth E. Gerard
- Comprehensive Epilepsy Center, Department of Neurology, Northwestern University, Chicago, Illinois, U.S.A
| | | | - Hiba Arif Haider
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Gamaleldin Osman
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Andres Rodriguez-Ruiz
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Carolina B. Maciel
- Division of Neurocritical Care, Department of Neurology, University of Florida, Gainesville, Florida, U.S.A
| | - Emily J. Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Andres Fernandez
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Jan Claassen
- Neurocritical Care, Department of Neurology, Columbia University, New York, New York, U.S.A
| | - Aatif M. Husain
- Department of Medicine (Neurology), Duke University Medical Center, and Veterans Affairs Medical Center, Durham, North Carolina, U.S.A
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Elson L. So
- Division of Epilepsy, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Peter W. Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
| | - Marc R. Nuwer
- Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, U.S.A
| | - Michel van Putten
- Medisch Spectrum Twente and University of Twente, Enschede, The Netherlands
| | - Raoul Sutter
- Medical Intensive Care Units and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Frank W. Drislane
- Department of Neurology, Harvard Medical School, and Comprehensive Epilepsy Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Nicolas Gaspard
- Department of Neurology, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
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Abstract
Generalized periodic discharges with triphasic morphology (GPDs + TWm) have been reported with multiple metabolic and drug toxicities. Beta-lactam antibiotics in some cases can cause neurotoxicity with GPDs + TWm on EEG. There are no reports in the literature of aztreonam causing neurotoxicity and GPDs + TWm. Here we describe GPDs + TWm and encephalopathy developing in a patient with underlying dementia and acute kidney injury who was started on aztreonam for cystitis. Neurotoxic effects of beta-lactam antibiotics have been well studied at this point, likely related to GABA receptor antagonism by the beta lactam ring. Risk factors for toxicity include, advanced age, prior neurological injury and decreased renal clearance. This patient carried multiple risk factors for beta-lactam neurotoxicity. Discontinuation of aztreonam led to a resolution of GPDs + TWm on EEG, and regression of encephalopathy.
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Affiliation(s)
- Andrew Billnitzer
- Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Peter W Kaplan
- Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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30
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Abstract
Status epilepticus (SE) is the state of continuous or repetitive seizures, which can occur with or without convulsions. Evolving definitions of SE take into account the concept that neuronal injury may occur at different times in different types of SE.SE that does not respond to initial treatment may become refractory or even super-refractory. Nonconvulsive SE is increasingly recognized in comatose patients in critical care units, with the growing use of continuous electroencephalogram monitoring. SE is a neurologic emergency that carries a high risk of mortality and morbidity.
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Affiliation(s)
- Emily L Johnson
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
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31
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Gélisse P, Rossetti AO, Genton P, Crespel A, Kaplan PW. How to carry out and interpret EEG recordings in COVID-19 patients in ICU? Clin Neurophysiol 2020; 131:2023-2031. [PMID: 32405259 PMCID: PMC7217782 DOI: 10.1016/j.clinph.2020.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 01/05/2023]
Abstract
There are questions and challenges regarding neurologic complications in COVID-19 patients. EEG is a safe and efficient tool for the evaluation of brain function, even in the context of COVID-19. However, EEG technologists should not be put in danger if obtaining an EEG does not significantly advance diagnosis or change management in the patient. Not every neurologic problem stems from a primary brain injury: confusion, impaired consciousness that evolves to stupor and coma, and headaches are frequent in hypercapnic/hypoxic encephalopathies. In patients with chronic pulmonary disorders, acute symptomatic seizures have been reported in acute respiratory failure in 6%. The clinician should be aware of the various EEG patterns in hypercapnic/hypoxic and anoxic (post-cardiac arrest syndrome) encephalopathies as well as encephalitides. In this emerging pandemic of infectious disease, reduced EEG montages using single-use subdermal EEG needle electrodes may be used in comatose patients. A full 10-20 EEG complement of electrodes with an ECG derivation remains the standard. Under COVID-19 conditions, an expedited study that adequately screens for generalized status epilepticus, most types of regional status epilepticus, encephalopathy or sleep may serve for most clinical questions, using simplified montages may limit the risk of infection to EEG technologists. We recommend noting whether the patient is undergoing or has been placed prone, as well as noting the body and head position during the EEG recording (supine versus prone) to avoid overinterpretation of respiratory, head movement, electrode, muscle or other artifacts. There is slight elevation of intracranial pressure in the prone position. In non-comatose patients, the hyperventilation procedure should be avoided. At present, non-specific EEG findings and abnormalities should not be considered as being specific for COVID-19 related encephalopathy.
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Affiliation(s)
- Philippe Gélisse
- Epilepsy Unit, Hôpital Gui de Chauliac, Montpellier, France; Research Unit (URCMA: Unité de Recherche sur les Comportements et Mouvements Anormaux), INSERM, U661, Montpellier F-34000, France.
| | - Andrea O Rossetti
- Department of Clinical Neuroscience, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Pierre Genton
- Neurology Department, Hôpital Saint Charles, 13100 Aix en Provence, France
| | - Arielle Crespel
- Epilepsy Unit, Hôpital Gui de Chauliac, Montpellier, France; Research Unit (URCMA: Unité de Recherche sur les Comportements et Mouvements Anormaux), INSERM, U661, Montpellier F-34000, France
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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32
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Affiliation(s)
- Michael O Kinney
- Department of Neurology, Royal Victoria Hospital, Grosvenor Road, Belfast, Co. Antrim, Northern Ireland, United Kingdom.
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224, USA
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33
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Ma GJ, Yadav S, Kaplan PW, Johnson E. New-onset epilepsy in women with first time seizures during pregnancy. Seizure 2020; 80:42-45. [PMID: 32521501 DOI: 10.1016/j.seizure.2020.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION In women with epilepsy, seizure frequency and severity can be affected during pregnancy by factors such as changes in ASD (anti-seizure drug) metabolism, changes in hormone levels, and medication compliance. Some women with epilepsy experience seizure worsening during pregnancy, while others have an improvement. Most epileptic seizures during pregnancy occur in women with pre-existing epilepsy. Rarely, women develop new-onset seizure-like episodes concerning for epileptic seizures during pregnancy, posing a diagnostic and therapeutic challenge for the physician. METHODS To determine the frequency of new-onset seizures during pregnancy and the clinical course of those with new seizures, we performed a retrospective study of all women with concomitant diagnoses of pregnancy and seizures (excluding eclampsia) at the Johns Hopkins Medical Institutions over a five-year period. We calculated the frequency of events concerning for seizures during pregnancy, including first-lifetime events, and classified these events as epileptic seizures or as seizure mimics. For those with epileptic seizures, we followed up with the patient to determine whether seizures recurred in or after pregnancy, and whether treatment with anti-seizure medication was initiated. RESULTS Over a five-year period, 41,869 women received care at Johns Hopkins Medical Institutions during pregnancy. 84 women had at least one event concerning for seizure during their pregnancies. Of these, 11 had no prior history of seizures; 5 of these women were found to have first-time unprovoked epileptic seizures supported by epileptiform abnormalities on EEG. All women delivered at term with no major complications. Four of these women continued to have epileptic seizures after delivery. CONCLUSIONS New onset seizures during pregnancy were rare. Most women with first-time epileptic seizures during pregnancy also had epileptic seizures after pregnancy, indicating a first presentation of epilepsy.
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Affiliation(s)
- Grace J Ma
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, United States.
| | - Sanya Yadav
- University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, United States
| | - Emily Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, United States
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34
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Affiliation(s)
- Raoul Sutter
- Medical Intensive Care Units and Department of Neurology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland. .,Medical Faculty, University of Basel, Basel, Switzerland.
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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35
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Slooter AJC, Otte WM, Devlin JW, Arora RC, Bleck TP, Claassen J, Duprey MS, Ely EW, Kaplan PW, Latronico N, Morandi A, Neufeld KJ, Sharshar T, MacLullich AMJ, Stevens RD. Updated nomenclature of delirium and acute encephalopathy: statement of ten Societies. Intensive Care Med 2020; 46:1020-1022. [PMID: 32055887 PMCID: PMC7210231 DOI: 10.1007/s00134-019-05907-4] [Citation(s) in RCA: 174] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/19/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Room F06.149, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Wim M Otte
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, Department of Pediatric Neurology, and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Rakesh C Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Thomas P Bleck
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jan Claassen
- Department of Neurology and Neurosurgery, Columbia University Medical Center, New York City, NY, USA
| | - Matthew S Duprey
- School of Pharmacy, Northeastern University, Boston, MA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Quality Aging, Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicola Latronico
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, University of Brescia, Brescia, Italy
| | - Alessandro Morandi
- Department of Rehabilitation, Ancelle Hospital, Cremona, Italy.,Geriatric Research Group, Brescia, Italy
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tarek Sharshar
- Unité Neuropathologie Expérimentale, Département Infection Et Épidémiologie, Institut Pasteur, and Service D'Anesthésie-Réanimation, Hôpital Sainte-Anne, Université Paris-Descartes, Paris, France
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, and Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Robert D Stevens
- Departments of Anesthesiology, Critical Care Medicine, Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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36
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Gugger JJ, Geocadin RG, Kaplan PW. A multimodal approach using somatosensory evoked potentials for prognostication in hypoglycemic encephalopathy. Clin Neurophysiol Pract 2019; 4:194-197. [PMID: 31886445 PMCID: PMC6921239 DOI: 10.1016/j.cnp.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 06/21/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022] Open
Abstract
Hypoglycemic encephalopathy may be associated with poor neurological prognosis. Little data exists to guide prognostication in hypoglycemic encephalopathy. We describe a multimodal approach to prognostication in hypoglycemia. MRI, EEG, and SSEPs estimate severity of brain injury in hypoglycemic coma.
Objectives We present a case of a patient with hypoglycemic encephalopathy with loss of median nerve N20 somatosensory evoked potentials (SSEPs) and describe our multimodal approach to prognostication in hypoglycemic encephalopathy. Case The patient was a 67-year-old woman with type 2 diabetes and stage 5 chronic kidney disease hospitalized for hypoglycemic encephalopathy. SSEPs showed bilateral absence of the median nerve N20 response. She ultimately suffered a poor outcome. Discussion There are no high-quality evidence-based clinical, neurophysiologic, or imaging studies available to aid in neurologic outcome prediction in hypoglycemic encephalopathy. In our practice we use a multimodal approach to neurologic prognostication, similar to that used in coma after cardiac arrest that includes SSEPs, EEG, and brain MRI, which enables an estimate of the severity of brain injury. As the literature is largely based on small studies or case reports, and is extrapolated from the cardiac arrest literature, we caution against early prognostication and disposition including the withdrawal of care, to avoid a self-fulfilling prophecy.
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Affiliation(s)
- James J Gugger
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter W Kaplan
- Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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37
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Koffman L, Rincon F, Gomes J, Singh S, He Y, Ritzl E, Bleck TP, Kaplan PW, Nyquist P. Continuous Electroencephalographic Monitoring in the Intensive Care Unit: A Cross-Sectional Study. J Intensive Care Med 2019; 35:1235-1240. [DOI: 10.1177/0885066619849889] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Research on continuous electro-encephalographic monitoring (cEEG) in the intensive care unit (ICU) has previously focused on neuroscience ICUs. This study determines cEEG utilization within a sample of specialty ICUs world-wide. Methods: A cross-sectional electronic survey of attending level physicians across various intensive care settings. Twenty-five questions developed from consensus statements on the use of cEEG in the critically ill sent as an electronic survey. Results: Of all, 9344 were queried and 417 (4.5%) responses were analyzed with 309 (74%) from the United States and 74 (18%) internationally. Intensive care units were: medical (10%), surgical (6%), neurologic/neurosurgical (12%), cardiac (4%), trauma (3%), pediatrics (29%), burn (<1%), multidisciplinary (30%), and other (5%). Intensive care units were: academic (65%), community (18%), public (3%), military (1%), and other (13%). Specialized cEEG teams were available in 71% of ICUs. Rapid 24/7 access and cEEG interpretation was available in 32% of ICUs. Interpretation changed clinical management frequently (28%) and sometimes (45%). Conclusions: Despite guideline recommendations for cEEG use, there is a discordance between availability, night coverage, and immediate interpretation. Only 27% have institutional protocols for indications and duration of cEEG monitoring. Furthermore, cEEG may be underutilized in nonneurologic ICUs as well as ICUs in smaller nonacademic affiliated hospitals and those outside of the United States.
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Affiliation(s)
- Lauren Koffman
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Fred Rincon
- Cerebrovascular Disease and Neurocritical Care, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joao Gomes
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Sarabdeep Singh
- Department of Core Clinical Research and Biostatistics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yitian He
- University of Wisconsin-Madison, Madison, WI, USA
| | - Eva Ritzl
- Department of Neurology and Epilepsy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Thomas P. Bleck
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Peter W. Kaplan
- Department of Neurology and Epilepsy, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Paul Nyquist
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
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38
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Abstract
A recent assessment of the classification of nonconvulsive status epilepticus (NCSE) has incorporated the specific electroencephalographic (EEG) patterns on a syndromic basis. Such a clinical EEG syndromic approach may enable more accurate and expedited diagnosis of particular subtypes of NCSE so as to improve therapy. Herein, we review the characteristics of subacute encephalopathy with seizures in alcoholics syndrome, a subtype of focal NCSE occurring in chronic alcoholism with specific features, including encephalopathy, lateralized periodic discharges on the EEG, chronic microvascular ischemia on neuroimaging studies, and possible recurrence when chronic antiseizure treatment is stopped.
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Affiliation(s)
- José L Fernández-Torre
- 1 Department of Clinical Neurophysiology, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain.,2 Department of Physiology and Pharmacology, University of Cantabria (UNICAN), Santander, Cantabria, Spain.,3 Biomedical Research Institute (IDIVAL), Santander, Spain
| | - Peter W Kaplan
- 4 Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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39
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Fernández-Torre JL, Kaplan PW. Development of permanent brain damage after subacute encephalopathy with seizures in alcoholics (SESA Syndrome). J Neurol Sci 2019; 399:186. [DOI: 10.1016/j.jns.2019.02.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 02/22/2019] [Indexed: 11/26/2022]
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40
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Sutter R, Semmlack S, Opić P, Spiegel R, De Marchis GM, Hunziker S, Kaplan PW, Rüegg S, Marsch S. Untangling operational failures of the Status Epilepticus Severity Score (STESS). Neurology 2019; 92:e1948-e1956. [PMID: 30918093 DOI: 10.1212/wnl.0000000000007365] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/31/2018] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To uncover clinical characteristics leading to false outcome prediction of the Status Epilepticus Severity Score (STESS), a validated and broadly used clinical scoring system for outcome prediction in status epilepticus (SE). METHODS From 2005 to 2016, adult patients with SE treated at the University Hospital Basel, Switzerland, were included. To assess independent associations of variables differing between patients with false and correct prediction of death (STESS ≥ 3), multivariable logistic regression models were computed using automated selection. RESULTS Among 467 patients, 12% died. The median STESS was 3 (interquartile range 2-4). Regarding prediction of death, the STESS was false-positive in 51% and false-negative in 1%. Patients surviving despite having a STESS ≥3 had less fatal etiologies, less nonconvulsive SE with coma, and lower Charlson Comorbidity Index, Simplified Acute Physiology Score II, and Acute Physiology and Chronic Health Evaluation II scores. In multivariable analyses, odds for survival were high with SE types other than nonconvulsive status with coma and low with an increasing Charlson Comorbidity Index in patients with a STESS ≥ 3 (odds ratio [OR]for survival 4.23, 95% confidence interval [CI] 2.33-9.60; and ORfor survival 0.86, 95% CI 0.75-0.98). In patients with SE types other than nonconvulsive with coma, the STESS was mainly increased because they were frequently older than 65 years and had no seizure history. CONCLUSIONS The STESS frequently and inadequately predicts death especially in patients with SE other than nonconvulsive with coma and few comorbidities. Clinicians are urged to interpret a STESS ≥3 with caution in such patients.
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Affiliation(s)
- Raoul Sutter
- From the Clinic for Intensive Care Medicine (R. Sutter, S.S., P.O., R. Spiegel, S.M.), Department of Neurology (R. Sutter, G.M.D.M., S.R.), and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel; Medical Faculty of the University of Basel (R. Sutter, G.M.D.M., S.H., S.R., S.M.), Switzerland; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD.
| | - Saskia Semmlack
- From the Clinic for Intensive Care Medicine (R. Sutter, S.S., P.O., R. Spiegel, S.M.), Department of Neurology (R. Sutter, G.M.D.M., S.R.), and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel; Medical Faculty of the University of Basel (R. Sutter, G.M.D.M., S.H., S.R., S.M.), Switzerland; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Petra Opić
- From the Clinic for Intensive Care Medicine (R. Sutter, S.S., P.O., R. Spiegel, S.M.), Department of Neurology (R. Sutter, G.M.D.M., S.R.), and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel; Medical Faculty of the University of Basel (R. Sutter, G.M.D.M., S.H., S.R., S.M.), Switzerland; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Rainer Spiegel
- From the Clinic for Intensive Care Medicine (R. Sutter, S.S., P.O., R. Spiegel, S.M.), Department of Neurology (R. Sutter, G.M.D.M., S.R.), and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel; Medical Faculty of the University of Basel (R. Sutter, G.M.D.M., S.H., S.R., S.M.), Switzerland; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Gian Marco De Marchis
- From the Clinic for Intensive Care Medicine (R. Sutter, S.S., P.O., R. Spiegel, S.M.), Department of Neurology (R. Sutter, G.M.D.M., S.R.), and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel; Medical Faculty of the University of Basel (R. Sutter, G.M.D.M., S.H., S.R., S.M.), Switzerland; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Sabina Hunziker
- From the Clinic for Intensive Care Medicine (R. Sutter, S.S., P.O., R. Spiegel, S.M.), Department of Neurology (R. Sutter, G.M.D.M., S.R.), and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel; Medical Faculty of the University of Basel (R. Sutter, G.M.D.M., S.H., S.R., S.M.), Switzerland; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Peter W Kaplan
- From the Clinic for Intensive Care Medicine (R. Sutter, S.S., P.O., R. Spiegel, S.M.), Department of Neurology (R. Sutter, G.M.D.M., S.R.), and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel; Medical Faculty of the University of Basel (R. Sutter, G.M.D.M., S.H., S.R., S.M.), Switzerland; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Stephan Rüegg
- From the Clinic for Intensive Care Medicine (R. Sutter, S.S., P.O., R. Spiegel, S.M.), Department of Neurology (R. Sutter, G.M.D.M., S.R.), and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel; Medical Faculty of the University of Basel (R. Sutter, G.M.D.M., S.H., S.R., S.M.), Switzerland; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Stephan Marsch
- From the Clinic for Intensive Care Medicine (R. Sutter, S.S., P.O., R. Spiegel, S.M.), Department of Neurology (R. Sutter, G.M.D.M., S.R.), and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel; Medical Faculty of the University of Basel (R. Sutter, G.M.D.M., S.H., S.R., S.M.), Switzerland; and Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
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Freund B, Probasco JC, Cervenka MC, Sutter R, Kaplan PW. EEG Differences in Two Clinically Similar Rapid Dementias: Voltage-Gated Potassium Channel Complex-Associated Autoimmune Encephalitis and Creutzfeldt-Jakob Disease. Clin EEG Neurosci 2019; 50:121-128. [PMID: 29788790 DOI: 10.1177/1550059418774686] [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] [Indexed: 11/15/2022]
Abstract
Distinguishing treatable causes for rapidly progressive dementia from those that are incurable is vital. Creutzfeldt-Jakob disease (CJD) and voltage-gated potassium channel complex-associated autoimmune encephalitis (VGKC AE) are 2 such conditions with disparate outcomes and response to treatment. To determine the differences in electroencephalography between CJD and VGKC AE, we performed a retrospective review of medical records and examined clinical data, neuroimaging, and electroencephalographs performed in patients admitted for evaluation for rapidly progressive dementia diagnosed with CJD and VGKC AE at the Johns Hopkins Hospital and Bayview Medical Center between January 1, 2007 and December 31, 2015. More patients in the VGKC AE group had seizures (12/17) than those with CJD (3/14; P = .008). Serum sodium levels were lower in those with VGKC AE (P = .001). Cerebrospinal fluid (CSF) white blood cell count was higher in VGKC AE (P = .008). CSF protein 14-3-3 (P = .018) was more commonly detected in CJD, and tau levels were higher in those with CJD (P < .006). On neuroimaging, diffusion restriction in the cortex (P = .001), caudate (P < .001), and putamen (P = .001) was more frequent in CJD. Periodic sharp wave complexes (P = .001) and generalized suppressed activity (P = .008) were more common on initial EEG in CJD. On serial EEGs, generalized periodic discharges (P = .004), generalized suppressed activity (P=0.008), and periodic sharp wave complexes (P < .001) were detected more in CJD. This study shows that there are a number of differentiating features between CJD and VGKC AE, and electroencephalography can aid in their diagnoses. Performing serial EEGs better delineates these conditions.
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Affiliation(s)
- Brin Freund
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - John C Probasco
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Raoul Sutter
- Department of Neurology and Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Semmlack S, Kaplan PW, Spiegel R, De Marchis GM, Hunziker S, Tisljar K, Rüegg S, Marsch S, Sutter R. Illness severity scoring in status epilepticus—When
STESS
meets
APACHE II
,
SAPS II
, and
SOFA. Epilepsia 2018; 60:189-200. [DOI: 10.1111/epi.14623] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/24/2018] [Accepted: 11/25/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Saskia Semmlack
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
| | - Peter W. Kaplan
- Department of Neurology Johns Hopkins Bayview Medical Center Baltimore Maryland
| | - Rainer Spiegel
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
| | | | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine University Hospital Basel Basel Switzerland
- Medical Faculty of the University of Basel Basel Switzerland
| | - Kai Tisljar
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
| | - Stephan Rüegg
- Department of Neurology University Hospital Basel Basel Switzerland
| | - Stephan Marsch
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
- Medical Faculty of the University of Basel Basel Switzerland
| | - Raoul Sutter
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
- Department of Neurology University Hospital Basel Basel Switzerland
- Medical Faculty of the University of Basel Basel Switzerland
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43
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Sutter R, Semmlack S, Kaplan PW, Opić P, Marsch S, Rüegg S. Prolonged status epilepticus: Early recognition and prediction of full recovery in a 12-year cohort. Epilepsia 2018; 60:42-52. [DOI: 10.1111/epi.14603] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/22/2018] [Accepted: 10/22/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Raoul Sutter
- Clinic for Intensive Care Medicine; University Hospital Basel; Basel Switzerland
- Department of Neurology; University Hospital Basel; Basel Switzerland
- Medical Faculty of the University of Basel; Basel Switzerland
| | - Saskia Semmlack
- Clinic for Intensive Care Medicine; University Hospital Basel; Basel Switzerland
| | - Peter W. Kaplan
- Department of Neurology; Johns Hopkins Bayview Medical Center; Baltimore Maryland
| | - Petra Opić
- Clinic for Intensive Care Medicine; University Hospital Basel; Basel Switzerland
| | - Stephan Marsch
- Clinic for Intensive Care Medicine; University Hospital Basel; Basel Switzerland
- Medical Faculty of the University of Basel; Basel Switzerland
| | - Stephan Rüegg
- Department of Neurology; University Hospital Basel; Basel Switzerland
- Medical Faculty of the University of Basel; Basel Switzerland
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44
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Kaplan PW, Billnitzer A, Fernández-Torre JL. Subacute Encephalopathy With Seizures in Alcoholics (SESA) Presenting as Focal Nonconvulsive Status Epilepticus. Clin EEG Neurosci 2018; 49:414-416. [PMID: 29260591 DOI: 10.1177/1550059417747435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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] [Indexed: 11/16/2022]
Abstract
PURPOSE To acquaint readers with the underrecognized subacute encephalopathy with seizures in chronic alcoholics (SESA) that has more recently been associated with different types of status epilepticus. METHODS Case reports and review of the literature on SESA and nonconvulsive status epilepticus (NCSE). RESULTS Two cases: one with alternating bifrontoparietal NCSE, and one with focal, confusional NCSE, with imaging and EEG correlates. CONCLUSION Underrecognized SESA may present as NCSE with focal clinical, EEG and reversible diffusion-weighted MRI abnormalities, warranting expedited diagnosis and antiseizure treatment to minimize morbidity.
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Affiliation(s)
- Peter W Kaplan
- 1 Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew Billnitzer
- 2 Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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45
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Freund BE, Kaplan PW. Reader response: Clinical Reasoning: Prognostication after cardiac arrest: What do we really know? Neurology 2018; 91:102. [DOI: 10.1212/wnl.0000000000005769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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46
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Johnson EL, Kaplan PW. Introduction to Periodic Discharges Volume II. J Clin Neurophysiol 2018; 35:273. [DOI: 10.1097/wnp.0000000000000469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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47
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Postels DG, Wu X, Li C, Kaplan PW, Seydel KB, Taylor TE, Kousa YA, Idro R, Opoka R, John CC, Birbeck GL. Admission EEG findings in diverse paediatric cerebral malaria populations predict outcomes. Malar J 2018; 17:208. [PMID: 29783991 PMCID: PMC5963073 DOI: 10.1186/s12936-018-2355-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Electroencephalography at hospital presentation may offer important insights regarding prognosis that can inform understanding of cerebral malaria (CM) pathophysiology and potentially guide patient selection and risk stratification for future clinical trials. Electroencephalogram (EEG) findings in children with CM in Uganda and Malawi were compared and associations between admission EEG findings and outcome across this diverse population were assessed. Demographic, clinical and admission EEG data from Ugandan and Malawian children admitted from 2009 to 2012 with CM were gathered, and survivors assessed for neurological abnormalities at discharge. RESULTS 281 children were enrolled (Uganda n = 122, Malawi n = 159). The Malawian population was comprised only of retinopathy positive children (versus 72.5% retinopathy positive in Uganda) and were older (4.2 versus 3.7 years; p = 0.046), had a higher HIV prevalence (9.0 versus 2.8%; p = 0.042), and worse hyperlactataemia (7.4 versus 5.2 mmol/L; p < 0.001) on admission compared to the Ugandan children. EEG findings differed between the two groups in terms of average voltage and frequencies, reactivity, asymmetry, and the presence/absence of sleep architecture. In univariate analyses pooling EEG and outcomes data for both sites, higher average and maximum voltages, faster dominant frequencies, and retained reactivity were associated with survival (all p < 0.05). Focal slowing was associated with death (OR 2.93; 95% CI 1.77-7.30) and a lower average voltage was associated with neurological morbidity in survivors (p = 0.0032). CONCLUSIONS Despite substantial demographic and clinical heterogeneity between subjects in Malawi and Uganda as well as different EEG readers at each site, EEG findings on admission predicted mortality and morbidity. For CM clinical trials aimed at decreasing mortality or morbidity, EEG may be valuable for risk stratification and/or subject selection.
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Affiliation(s)
- Douglas G Postels
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, 909 Fee Road, 324 West Fee Hall, East Lansing, MI, 48824, USA. .,Department of Neurology, Children's National Health System, 111 Michigan Avenue NW, Washington, DC, 20010, USA.
| | - Xiaoting Wu
- Department of Epidemiology and Biostatistics, Michigan State University, 909 Fee Road, Room B601, East Lansing, MI, 48824, USA
| | - Chenxi Li
- Department of Epidemiology and Biostatistics, Michigan State University, 909 Fee Road, Room B601, East Lansing, MI, 48824, USA
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Karl B Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
| | - Terrie E Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
| | - Youssef A Kousa
- Department of Neurology, Children's National Health System, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Chandy C John
- Indiana University School of Medicine, 1044 W. Walnut Street, Rm 402-D, Indianapolis, IN, 46202, USA
| | - Gretchen L Birbeck
- Epilepsy Division, Department of Neurology, University of Rochester, 265 Crittenden Blvd, CU 420694, Rochester, NY, 14642, USA.,UTH Neurology Research Office, Nationalist Rd, PO Box UTH 11, Lusaka, Zambia
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48
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Punjabi NM, Kaplan PW, Margolick J, Aurora RN. 0319 A Simplified Bipolar Frontal Montage for Recording and Staging Sleep. Sleep 2018. [DOI: 10.1093/sleep/zsy061.318] [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: 11/13/2022] Open
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49
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Abstract
Non-convulsive status epilepticus (NCSE) is an enigmatic condition with protean manifestations. It often goes unrecognised, leading to delays in its diagnosis and treatment. The principal reason for such delay is the failure to consider and request an electroencephalogram (EEG), although occasional presentations have no scalp or surface electroencephalographic correlate. In certain settings with limited EEG availability, particularly out-of-hours, clinicians should consider treating without an EEG. Patients need a careful risk–benefit analysis to assess the risks of neuronal damage and harm versus the risks of adverse effects from various intensities of therapeutic intervention. Specialists in EEG, intensive care or epilepsy are invaluable in the management of patients with possible NCSE.
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Spoelhof B, Sanchez-Bautista J, Zorrilla-Vaca A, Kaplan PW, Farrokh S, Mirski M, Freund B, Rivera-Lara L. Abstract WMP105: A Meta-Analysis and Systematic Review of Antiepileptic Drugs for Seizure Prophylaxis on Long-Term Functional Outcomes in Patients With Acute Intracerebral Hemorrhage. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wmp105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Intracranial hemorrhage (ICH) is a devastating form of stroke that leads to development of seizures in up to 2%-40% of patients. Seizure prophylaxis in ICH remains controversial and it is unclear if the benefits of antiepileptic drugs (AEDs) outweigh the risk of potential adverse drug effects. The objective of this analysis is to assess the effect of AED on seizure prevention and long term functional outcomes in patients with acute ICH.
Methods:
Our group conducted a meta-analysis using the PRISMA guidelines. A literature search was performed of the PubMed, the Cochran Library, and EMBASE databases using the keywords “Anticonvulsants”, “Intracerebral Hemorrhage”, and related subject headings. Articles were screened and included if they assessed the impact of AEDs on long-term functional outcomes in ICH population using multivariate logistic regression analysis. Overall effect sizes were evaluated with forest plots and publication bias was assessed with the Begg’s and Egger’s tests. Long term functional outcomes were assessed at ≥ 3 months post-ICH with either the National Institute of Health Stroke Scale (NIHSS) or the modified Rankin Score (mRS).
Results:
A total of 3,912 articles were identified during the intimal review. After screening, 54 articles remained for full review and 6 articles were included in the final analysis. The quality assessment criteria ranged from moderate to high for evidence synthesis. A total of 3,193 patients were included in the analysis. There were no significant association between the use of AEDs after ICH and poor outcome defined as mRS ≥3 or NIHSS ≥15 (OR 1.53 [95% CI: 0.81-2.88] p=0.18, I
2
=81.7%). Only one trial evaluated the effect AEDs had in prevent post-ICH seizures. Publication bias was not observed in the analysis (Egger’s bias=2.23, P=0.23).
Conclusion:
In conclusion, the use of prophylactic AEDs was not associated with improved or worse functional outcomes after acute ICH.
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Affiliation(s)
- Brian Spoelhof
- Dept of Pharmacy, Lahey Hosp and Med Cntr, Burlington, MA
| | | | | | - Peter W Kaplan
- Dept of Neurology, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Salia Farrokh
- Dept of Pharmacy, The Johns Hopkins Hosp, Baltimore, MD
| | - Marek Mirski
- Dept of Neurology, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Brin Freund
- Dept of Neurology, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Lucia Rivera-Lara
- Dept of Neurology, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
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