This document discusses EEG abnormalities associated with brain tumors. It begins by reviewing the history and role of EEG in localizing brain lesions. It then describes common EEG findings seen with tumors, such as polymorphic delta activity and focal slowing, and how findings depend on tumor location, type, and other factors. Specifically, it outlines EEG characteristics of tumors in different brain regions and how patterns vary for tumors like meningiomas versus gliomas. The document provides an in-depth review of EEG changes that can occur with brain tumors.
1. PLEDs (Periodic Lateralized Epileptiform Discharges) are a pattern seen on EEG characterized by periodic discharges that are lateralized to one hemisphere.
2. They are commonly seen in conditions involving acute brain injury or inflammation such as stroke, encephalitis, tumors, or hypoxic ischemic encephalopathy.
3. PLEDs are associated with a risk of seizures but generally indicate an unstable brain state that will improve over time as the underlying condition resolves. Prognosis depends on the specific cause.
ECOG involves directly recording cortical electrical activity from the surface of the brain. It is used to localize epileptogenic regions and predict surgical outcomes. There are two main types - intraoperative ECOG during surgery and extraoperative ECOG for longer monitoring. Subdural grids and strips can be placed on the brain surface or depth electrodes can access deeper structures. ECOG is performed by placing electrode arrays on the exposed brain during a craniotomy procedure. It provides valuable data to identify seizure foci but also carries risks like infection if implanted for longer periods.
The document discusses normal neonatal EEG patterns. It describes the typical EEG background patterns seen at different conceptional ages, including trace discontinu, mixed voltage, and high voltage slow patterns. It discusses normal developmental milestones, such as the development of interhemispheric synchrony and continuity. The document also describes normal transient patterns like frontal sharp transients and rolandic dips/sharps. Parameters for distinguishing sleep stages are provided, along with typical sleep-wake cycles at different ages. Guidelines are given for determining what constitutes an abnormal EEG finding in neonates.
The document discusses how different drugs can affect EEG interpretation. It notes that the quantity of medication in a patient influences the EEG, depending on factors like dose and metabolism. It provides examples of specific drugs that may elicit different EEG patterns, such as background slowing with phenytoin, excess beta with GABA agonists like barbiturates and benzodiazepines, epileptiform activity, triphasic waves, theta and delta activity, and coma patterns. Certain medications are also more likely to produce beta activity in children versus adults or with acute versus chronic use. Very high doses of some medications can cause spikes or polyspikes. Diffuse delta and excess theta may indicate neurotoxicity associated with certain anti-
Normal EEG patterns, frequencies, as well as patterns that may simulate diseaseRahul Kumar
This presentation discusses the vast range of traces that show the variations in normal EEG patterns, as well as discussing the frequency and amplitudes of various normal waveforms.
Brainstem Auditory Evoked Potentials (BAEP) involves recording electrophysiological responses from the ear in response to auditory stimulation to assess the functioning of the auditory pathway. BAEP testing involves placing electrodes on the scalp to record waveforms representing activity in the auditory nerve and brainstem in response to click sounds. BAEP is useful for screening and monitoring conditions affecting the auditory pathway such as tumors near the cerebellopontine angle, multiple sclerosis, and coma. It can also be used for newborn hearing screening and evaluating stroke and tuberculous meningitis patients.
EEG in idiopathic generalised epilepsiesNeurologyKota
This document provides information on idiopathic generalized epilepsies (IGE), which are a group of epilepsy disorders characterized by generalized bilateral spike-wave complexes on EEG. It describes the main seizure types seen in IGE including absence seizures, myoclonic seizures, and generalized tonic-clonic seizures. It also discusses several specific IGE syndromes like childhood absence epilepsy, juvenile absence epilepsy, and juvenile myoclonic epilepsy. For each syndrome it provides details on clinical presentation, EEG features, treatment approaches, and prognosis.
This document discusses encephalopathy and summarizes key points about its causes, features on EEG, and types. Encephalopathy is defined as altered brain function resulting in impaired consciousness. It can be caused by metabolic, toxic, infectious, hepatic or other issues. On EEG, encephalopathy typically shows generalized slowing and reduced reactivity. Specific patterns like triphasic waves indicate metabolic encephalopathy. The document outlines different types of encephalopathy and their associated EEG findings to help evaluate severity and guide treatment.
1. PLEDs (Periodic Lateralized Epileptiform Discharges) are a pattern seen on EEG characterized by periodic discharges that are lateralized to one hemisphere.
2. They are commonly seen in conditions involving acute brain injury or inflammation such as stroke, encephalitis, tumors, or hypoxic ischemic encephalopathy.
3. PLEDs are associated with a risk of seizures but generally indicate an unstable brain state that will improve over time as the underlying condition resolves. Prognosis depends on the specific cause.
ECOG involves directly recording cortical electrical activity from the surface of the brain. It is used to localize epileptogenic regions and predict surgical outcomes. There are two main types - intraoperative ECOG during surgery and extraoperative ECOG for longer monitoring. Subdural grids and strips can be placed on the brain surface or depth electrodes can access deeper structures. ECOG is performed by placing electrode arrays on the exposed brain during a craniotomy procedure. It provides valuable data to identify seizure foci but also carries risks like infection if implanted for longer periods.
The document discusses normal neonatal EEG patterns. It describes the typical EEG background patterns seen at different conceptional ages, including trace discontinu, mixed voltage, and high voltage slow patterns. It discusses normal developmental milestones, such as the development of interhemispheric synchrony and continuity. The document also describes normal transient patterns like frontal sharp transients and rolandic dips/sharps. Parameters for distinguishing sleep stages are provided, along with typical sleep-wake cycles at different ages. Guidelines are given for determining what constitutes an abnormal EEG finding in neonates.
The document discusses how different drugs can affect EEG interpretation. It notes that the quantity of medication in a patient influences the EEG, depending on factors like dose and metabolism. It provides examples of specific drugs that may elicit different EEG patterns, such as background slowing with phenytoin, excess beta with GABA agonists like barbiturates and benzodiazepines, epileptiform activity, triphasic waves, theta and delta activity, and coma patterns. Certain medications are also more likely to produce beta activity in children versus adults or with acute versus chronic use. Very high doses of some medications can cause spikes or polyspikes. Diffuse delta and excess theta may indicate neurotoxicity associated with certain anti-
Normal EEG patterns, frequencies, as well as patterns that may simulate diseaseRahul Kumar
This presentation discusses the vast range of traces that show the variations in normal EEG patterns, as well as discussing the frequency and amplitudes of various normal waveforms.
Brainstem Auditory Evoked Potentials (BAEP) involves recording electrophysiological responses from the ear in response to auditory stimulation to assess the functioning of the auditory pathway. BAEP testing involves placing electrodes on the scalp to record waveforms representing activity in the auditory nerve and brainstem in response to click sounds. BAEP is useful for screening and monitoring conditions affecting the auditory pathway such as tumors near the cerebellopontine angle, multiple sclerosis, and coma. It can also be used for newborn hearing screening and evaluating stroke and tuberculous meningitis patients.
EEG in idiopathic generalised epilepsiesNeurologyKota
This document provides information on idiopathic generalized epilepsies (IGE), which are a group of epilepsy disorders characterized by generalized bilateral spike-wave complexes on EEG. It describes the main seizure types seen in IGE including absence seizures, myoclonic seizures, and generalized tonic-clonic seizures. It also discusses several specific IGE syndromes like childhood absence epilepsy, juvenile absence epilepsy, and juvenile myoclonic epilepsy. For each syndrome it provides details on clinical presentation, EEG features, treatment approaches, and prognosis.
This document discusses encephalopathy and summarizes key points about its causes, features on EEG, and types. Encephalopathy is defined as altered brain function resulting in impaired consciousness. It can be caused by metabolic, toxic, infectious, hepatic or other issues. On EEG, encephalopathy typically shows generalized slowing and reduced reactivity. Specific patterns like triphasic waves indicate metabolic encephalopathy. The document outlines different types of encephalopathy and their associated EEG findings to help evaluate severity and guide treatment.
An electroencephalogram (EEG) is a test used to evaluate the electrical activity in the brain. Brain cells communicate with each other through electrical impulses. An EEG can be used to help detect potential problems associated with this activity.
EEG variants, are always to be recognized while interpreting the EEG one must be aware of these. Major and most common EEG is variants are discussed in the stated presentation.
Syed Irshad Murtaza.
Presurgical Evaluation Of Intractable EpilepsyNeurologyKota
The document discusses the presurgical evaluation of patients with intractable epilepsy. It describes how the goal is to localize the epileptogenic zone and assess risk to functions. Various tests are used to define zones like the ictal onset zone and irritative zone. Imaging like MRI, PET, SPECT and other tests help localize the epileptogenic lesion and functional deficits. Comprehensive presurgical evaluation including neuropsychological testing is needed to determine surgical candidacy and plan appropriate treatment.
PET imaging can help diagnose and monitor Parkinson's disease. PET tracers target different aspects of the dopaminergic system, including dopamine synthesis with 18F-DOPA, dopamine storage with 11C-DTBZ, dopamine transporters with 18F-FP-CIT, and dopamine receptors with 11C-raclopride. 18F-DOPA and 11C-DTBZ PET show reduced uptake in the striatum, especially the putamen, in Parkinson's patients compared to controls. 18F-FP-CIT and other DAT tracer PET also show reduced striatal uptake. FDG-PET shows increased metabolism in the putamen and globus pallidus but decreased metabolism in frontal and parietal cort
This presentation looks at generalised periodic epileptiform discharges and the various disorders like Creutzfeldt Jacob disease (CJD), SSPE and metabolic encephalopathies in which it is seen. SIRPID is also discussed. Triphasic waves are described. Radermacker complexes in SSPE are described.
The document discusses normal EEG patterns in various age groups from neonatal to adulthood. In neonates, the EEG pattern depends on gestational age and includes discontinuity in premature infants. In infancy and early childhood, the posterior dominant rhythm increases in frequency and reactivity emerges. By adolescence, the EEG begins to resemble the adult pattern with less delta activity. The normal adult EEG shows an alpha rhythm over the occipital lobe that attenuates with eye opening. Theta is only present in sleep while delta is never seen in awake adults.
This document discusses posterior slow waves of youth, also known as youth waves or polyphasic waves. It provides details on the following:
- These waves are high-voltage theta or delta waves seen in children aged 8-14 years that are accompanied by the alpha rhythm.
- They typically appear unilaterally or bilaterally and are attenuated with eye opening.
- Examples are shown from EEGs of children ages 9-10 years exhibiting occipital slow waves mixing with and interrupting the alpha rhythm.
- Characteristics including incidence, voltage ratio, persistence with eye opening, and symmetry are discussed. An example shows intermittent right occipital delta slowing in an 8-year-old
This document discusses epilepsy management in patients with comorbid systemic disorders. It focuses on how liver disease, kidney disease, porphyria, infections, brain tumors, and strokes can impact epilepsy treatment. For liver disease, levetiracetam, lacosamide, topiramate, gabapentin and pregabalin are recommended first-line therapies due to their limited hepatic metabolism and excretion. For kidney disease, drug dosages may need adjustment based on creatinine clearance levels. Non-enzyme inducing antiepileptic drugs are preferred for patients with porphyria or infections. Levetiracetam has shown efficacy for brain tumor-related seizures while minimizing interactions with cancer treatments. Interactions with other medications
Event Related Potentials, Cognitive Evoked Potentials. These are stimulus unrelated potentials, which depend on the patient's ability to differentiate between a rare stimulus and a common stimulus.
EEG artifacts can arise from various physiological and extraphysiological sources other than brain activity. Physiological artifacts originate from the patient's own generator sources like eye movements, muscle activity, movement, and cardiac activity. Extraphysiological artifacts are externally generated, such as from medical devices, electrical equipment, or the environment. Common EEG artifacts include cardiac artifacts like ECG signals, ballistocardiographic artifacts from head or body movement, pacemaker signals, and pulse artifacts. Electrode artifacts can be transient pops or low frequency rhythms across electrodes from poor contact or movement. External artifacts include 50/60 Hz ambient noise, intravenous drips, and signals from devices like pumps and ventilators. Muscle and ocular artifacts
Multiple sleep latency Test (MSLT) and Maintenance of Wakefulness Test (MWT) ...Murtaza Syed
The document provides information about the Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test (MWT). It describes how MSLT is used to test for excessive daytime sleepiness by measuring how quickly a person falls asleep during nap opportunities. Abnormally short sleep latencies or two or more sleep onset REM periods indicate narcolepsy. MWT measures ability to stay awake and is used to assess treatment effectiveness. Both tests involve daytime nap recordings preceded by an overnight sleep study and use similar protocols and equipment to objectively measure sleepiness and wakefulness.
This document provides information about brainstem auditory evoked potentials (BAEPs). It discusses the anatomy and physiology of the peripheral and central auditory systems, including the pathways from the inner ear to the brainstem and cortex. It describes the generators of BAEP waveforms and standards for BAEP testing according to the American Clinical Neurophysiology Society, including stimulus parameters, recording settings, and analysis time. The document is intended to inform readers about BAEP testing and interpretation.
Intra operative neurophysiological monitoringKode Sashanka
This document discusses intra-operative neurophysiological monitoring during surgeries. It provides an overview of the need for monitoring, the types of monitoring used, and how they work. Monitoring includes EEG, somatosensory evoked potentials, motor evoked potentials, and more. These techniques provide real-time feedback on the functional status of the nervous system during surgery to help reduce risks. Anesthetic management and different monitoring systems are also reviewed.
This document describes several benign EEG variants that can have an epileptiform appearance but are not epileptogenic. It discusses characteristics of alpha variants, mu rhythm, lambda waves, rhythmic mid-temporal theta discharges, wicket spikes, subclinical rhythmic electroencephalographic discharges of adults, phantom spike-wave discharges, and small sharp spikes. These benign variants can occur during drowsiness and light sleep and are seen in specific electrode sites, with features like attenuation with eye opening or movement in the case of mu rhythm. Accurate identification requires training to distinguish them from true epileptiform discharges.
Evoked potentials are electrical signals produced by the nervous system in response to external stimuli. The document discusses several types of evoked potentials including brainstem auditory evoked potentials (BAEP), visual evoked potentials (VEP), and somatosensory evoked potentials (SEP). For BAEP, electrodes are placed on the ear and vertex to assess conduction through the auditory pathway up to the midbrain. VEP involves recording potentials from the scalp in response to visual stimuli to evaluate visual function. SEP evaluates sensory pathways from peripheral nerves to the spinal cord and cortex by stimulating nerves like the median and posterior tibial. The document outlines the electrode placement, stimulation parameters, and normal/abnormal findings for these ev
- The EEG records electrical activity from the cerebral cortex which is amplified over 10 million times to be visible. It detects action potentials and post-synaptic potentials from neurons.
- Electrodes are placed on standardized locations on the scalp according to the 10-20 or 10-10 systems to allow comparison across studies. Recordings can be bipolar between adjacent electrodes or referential against a common electrode.
- Activity is recorded through amplifiers and can be displayed through different montages optimized for localization or overall brain activity. Calibration ensures consistent sensitivity and filtering removes unwanted interference.
This pattern discusses the various EEG patterns seen in term as well as pre term neonates. Normal Variations as well as pathological traces are discussed
Repetitive nerve stimulation (RNS) involves electrically stimulating a nerve multiple times and measuring the response of the muscle. It is useful for diagnosing neuromuscular junction disorders. There are two main types - slow RNS at 3-5 Hz and rapid RNS at 20-50 Hz. The test evaluates changes in the compound muscle action potential (CMAP) amplitude between stimuli and with activation maneuvers. Specific patterns of response on RNS can help localize defects as pre-synaptic or post-synaptic. RNS, along with single fiber EMG, are key tests for diagnosing myasthenia gravis and other neuromuscular transmission disorders.
The temporal lobe plays important roles in processing sensory input such as auditory and visual information. It is involved in functions such as memory formation, emotion processing, and language comprehension. Damage to temporal lobe structures can cause symptoms like auditory or visual processing issues, memory impairments, and changes in emotional behavior or personality. The superior, middle, and inferior temporal gyri and medial temporal structures each contribute to these various temporal lobe functions.
1 basics of eeg and fundamentals of its measurementSwathy Ravi
The document discusses the basics of EEG and its measurement. It provides a timeline of EEG invention from 1875 to 1924. It describes how EEG signals are generated from neuronal structures and propagated through electrical signals. It explains how EEG is recorded using a modern EEG machine and electrode placement systems. It discusses filters, amplifiers, polarity conventions, montages, artifacts, and clinical applications of EEG for monitoring brain activity.
Issues in brainmapping...The role of EEG in epileptic syndromes associated wi...Professor Yasser Metwally
1. EEG is essential for evaluating epilepsy and can provide information about background activity, epileptiform discharges, and help diagnose specific epilepsy syndromes.
2. The document discusses various epilepsy syndromes like symptomatic, cryptogenic, and idiopathic epilepsy and how EEG characteristics help differentiate these.
3. Specific syndromes discussed include infantile spasms and West syndrome, characterized by hypsarrhythmia on EEG, and Lennox-Gastaut syndrome, characterized by slow spike and wave activity on EEG.
An electroencephalogram (EEG) is a test used to evaluate the electrical activity in the brain. Brain cells communicate with each other through electrical impulses. An EEG can be used to help detect potential problems associated with this activity.
EEG variants, are always to be recognized while interpreting the EEG one must be aware of these. Major and most common EEG is variants are discussed in the stated presentation.
Syed Irshad Murtaza.
Presurgical Evaluation Of Intractable EpilepsyNeurologyKota
The document discusses the presurgical evaluation of patients with intractable epilepsy. It describes how the goal is to localize the epileptogenic zone and assess risk to functions. Various tests are used to define zones like the ictal onset zone and irritative zone. Imaging like MRI, PET, SPECT and other tests help localize the epileptogenic lesion and functional deficits. Comprehensive presurgical evaluation including neuropsychological testing is needed to determine surgical candidacy and plan appropriate treatment.
PET imaging can help diagnose and monitor Parkinson's disease. PET tracers target different aspects of the dopaminergic system, including dopamine synthesis with 18F-DOPA, dopamine storage with 11C-DTBZ, dopamine transporters with 18F-FP-CIT, and dopamine receptors with 11C-raclopride. 18F-DOPA and 11C-DTBZ PET show reduced uptake in the striatum, especially the putamen, in Parkinson's patients compared to controls. 18F-FP-CIT and other DAT tracer PET also show reduced striatal uptake. FDG-PET shows increased metabolism in the putamen and globus pallidus but decreased metabolism in frontal and parietal cort
This presentation looks at generalised periodic epileptiform discharges and the various disorders like Creutzfeldt Jacob disease (CJD), SSPE and metabolic encephalopathies in which it is seen. SIRPID is also discussed. Triphasic waves are described. Radermacker complexes in SSPE are described.
The document discusses normal EEG patterns in various age groups from neonatal to adulthood. In neonates, the EEG pattern depends on gestational age and includes discontinuity in premature infants. In infancy and early childhood, the posterior dominant rhythm increases in frequency and reactivity emerges. By adolescence, the EEG begins to resemble the adult pattern with less delta activity. The normal adult EEG shows an alpha rhythm over the occipital lobe that attenuates with eye opening. Theta is only present in sleep while delta is never seen in awake adults.
This document discusses posterior slow waves of youth, also known as youth waves or polyphasic waves. It provides details on the following:
- These waves are high-voltage theta or delta waves seen in children aged 8-14 years that are accompanied by the alpha rhythm.
- They typically appear unilaterally or bilaterally and are attenuated with eye opening.
- Examples are shown from EEGs of children ages 9-10 years exhibiting occipital slow waves mixing with and interrupting the alpha rhythm.
- Characteristics including incidence, voltage ratio, persistence with eye opening, and symmetry are discussed. An example shows intermittent right occipital delta slowing in an 8-year-old
This document discusses epilepsy management in patients with comorbid systemic disorders. It focuses on how liver disease, kidney disease, porphyria, infections, brain tumors, and strokes can impact epilepsy treatment. For liver disease, levetiracetam, lacosamide, topiramate, gabapentin and pregabalin are recommended first-line therapies due to their limited hepatic metabolism and excretion. For kidney disease, drug dosages may need adjustment based on creatinine clearance levels. Non-enzyme inducing antiepileptic drugs are preferred for patients with porphyria or infections. Levetiracetam has shown efficacy for brain tumor-related seizures while minimizing interactions with cancer treatments. Interactions with other medications
Event Related Potentials, Cognitive Evoked Potentials. These are stimulus unrelated potentials, which depend on the patient's ability to differentiate between a rare stimulus and a common stimulus.
EEG artifacts can arise from various physiological and extraphysiological sources other than brain activity. Physiological artifacts originate from the patient's own generator sources like eye movements, muscle activity, movement, and cardiac activity. Extraphysiological artifacts are externally generated, such as from medical devices, electrical equipment, or the environment. Common EEG artifacts include cardiac artifacts like ECG signals, ballistocardiographic artifacts from head or body movement, pacemaker signals, and pulse artifacts. Electrode artifacts can be transient pops or low frequency rhythms across electrodes from poor contact or movement. External artifacts include 50/60 Hz ambient noise, intravenous drips, and signals from devices like pumps and ventilators. Muscle and ocular artifacts
Multiple sleep latency Test (MSLT) and Maintenance of Wakefulness Test (MWT) ...Murtaza Syed
The document provides information about the Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test (MWT). It describes how MSLT is used to test for excessive daytime sleepiness by measuring how quickly a person falls asleep during nap opportunities. Abnormally short sleep latencies or two or more sleep onset REM periods indicate narcolepsy. MWT measures ability to stay awake and is used to assess treatment effectiveness. Both tests involve daytime nap recordings preceded by an overnight sleep study and use similar protocols and equipment to objectively measure sleepiness and wakefulness.
This document provides information about brainstem auditory evoked potentials (BAEPs). It discusses the anatomy and physiology of the peripheral and central auditory systems, including the pathways from the inner ear to the brainstem and cortex. It describes the generators of BAEP waveforms and standards for BAEP testing according to the American Clinical Neurophysiology Society, including stimulus parameters, recording settings, and analysis time. The document is intended to inform readers about BAEP testing and interpretation.
Intra operative neurophysiological monitoringKode Sashanka
This document discusses intra-operative neurophysiological monitoring during surgeries. It provides an overview of the need for monitoring, the types of monitoring used, and how they work. Monitoring includes EEG, somatosensory evoked potentials, motor evoked potentials, and more. These techniques provide real-time feedback on the functional status of the nervous system during surgery to help reduce risks. Anesthetic management and different monitoring systems are also reviewed.
This document describes several benign EEG variants that can have an epileptiform appearance but are not epileptogenic. It discusses characteristics of alpha variants, mu rhythm, lambda waves, rhythmic mid-temporal theta discharges, wicket spikes, subclinical rhythmic electroencephalographic discharges of adults, phantom spike-wave discharges, and small sharp spikes. These benign variants can occur during drowsiness and light sleep and are seen in specific electrode sites, with features like attenuation with eye opening or movement in the case of mu rhythm. Accurate identification requires training to distinguish them from true epileptiform discharges.
Evoked potentials are electrical signals produced by the nervous system in response to external stimuli. The document discusses several types of evoked potentials including brainstem auditory evoked potentials (BAEP), visual evoked potentials (VEP), and somatosensory evoked potentials (SEP). For BAEP, electrodes are placed on the ear and vertex to assess conduction through the auditory pathway up to the midbrain. VEP involves recording potentials from the scalp in response to visual stimuli to evaluate visual function. SEP evaluates sensory pathways from peripheral nerves to the spinal cord and cortex by stimulating nerves like the median and posterior tibial. The document outlines the electrode placement, stimulation parameters, and normal/abnormal findings for these ev
- The EEG records electrical activity from the cerebral cortex which is amplified over 10 million times to be visible. It detects action potentials and post-synaptic potentials from neurons.
- Electrodes are placed on standardized locations on the scalp according to the 10-20 or 10-10 systems to allow comparison across studies. Recordings can be bipolar between adjacent electrodes or referential against a common electrode.
- Activity is recorded through amplifiers and can be displayed through different montages optimized for localization or overall brain activity. Calibration ensures consistent sensitivity and filtering removes unwanted interference.
This pattern discusses the various EEG patterns seen in term as well as pre term neonates. Normal Variations as well as pathological traces are discussed
Repetitive nerve stimulation (RNS) involves electrically stimulating a nerve multiple times and measuring the response of the muscle. It is useful for diagnosing neuromuscular junction disorders. There are two main types - slow RNS at 3-5 Hz and rapid RNS at 20-50 Hz. The test evaluates changes in the compound muscle action potential (CMAP) amplitude between stimuli and with activation maneuvers. Specific patterns of response on RNS can help localize defects as pre-synaptic or post-synaptic. RNS, along with single fiber EMG, are key tests for diagnosing myasthenia gravis and other neuromuscular transmission disorders.
The temporal lobe plays important roles in processing sensory input such as auditory and visual information. It is involved in functions such as memory formation, emotion processing, and language comprehension. Damage to temporal lobe structures can cause symptoms like auditory or visual processing issues, memory impairments, and changes in emotional behavior or personality. The superior, middle, and inferior temporal gyri and medial temporal structures each contribute to these various temporal lobe functions.
1 basics of eeg and fundamentals of its measurementSwathy Ravi
The document discusses the basics of EEG and its measurement. It provides a timeline of EEG invention from 1875 to 1924. It describes how EEG signals are generated from neuronal structures and propagated through electrical signals. It explains how EEG is recorded using a modern EEG machine and electrode placement systems. It discusses filters, amplifiers, polarity conventions, montages, artifacts, and clinical applications of EEG for monitoring brain activity.
Issues in brainmapping...The role of EEG in epileptic syndromes associated wi...Professor Yasser Metwally
1. EEG is essential for evaluating epilepsy and can provide information about background activity, epileptiform discharges, and help diagnose specific epilepsy syndromes.
2. The document discusses various epilepsy syndromes like symptomatic, cryptogenic, and idiopathic epilepsy and how EEG characteristics help differentiate these.
3. Specific syndromes discussed include infantile spasms and West syndrome, characterized by hypsarrhythmia on EEG, and Lennox-Gastaut syndrome, characterized by slow spike and wave activity on EEG.
Hepatic encephalopathy is a syndrome characterized by personality changes, impaired intellect, and depressed consciousness that occurs in patients with cirrhosis of the liver. An important prerequisite is the diversion of portal blood into systemic circulation through portosystemic shunts. Subtle signs are seen in 70% of cirrhosis patients, with symptoms debilitating in 24-53% of those with portosystemic shunt surgery. Triphasic waves seen on EEGs are nonspecific but classic for hepatic encephalopathy. While commonly caused by hepatic or renal failure, triphasic waves can result from various toxic, metabolic, or structural abnormalities.
This document summarizes a case report of a 33-year-old patient presenting with paraplegia and sensory loss. An MRI showed a central spinal cord T2 hyperintensity involving 3-8 segments, consistent with a diagnosis of acute postinfectious transverse myelitis. The case report is edited by Professor Yasser Metwally and includes 3 figures and a table describing characteristic MRI findings of transverse myelitis.
The document discusses a study of 11 patients with surgically confirmed degenerative dorsal disc herniation. Clinical exams and tests found higher rates of vascular risk factors and increased blood viscosity in these patients compared to controls. MRI and CT myelography showed partially or heavily calcified disc herniations in the lower dorsal spine. The clinical presentation was characterized by a mainly motor myelopathy with remissions and exacerbations. The findings help explain the pathogenesis and clinical presentation of myelopathy from degenerative dorsal disc disease.
This document summarizes a case study of a 37-year-old female patient who presented with Parinaud syndrome. She had first noticed eye movement abnormalities at age 12 but did not seek medical care until age 37. An MRI revealed a tectal plate glioma (focal midbrain glioma). The tumor enhanced with contrast and appeared hyperintense on T2-weighted MRI. The patient's condition remained stable with follow-up MRIs every two years.
This document summarizes a case study of spinal multiple sclerosis seen on MRI imaging. It includes the following key points:
1) MRI images of the patient show multiple well-defined pencil-shaped lesions occupying 2-3 spinal segments that appear hypointense on T1-weighted images and hyperintense on T2-weighted images.
2) The lesions are characteristic of multiple sclerosis and located peripherally within the spinal cord.
3) The imaging and clinical presentation lead to a diagnosis of spinal multiple sclerosis.
This document summarizes a case report of a 22-year-old male patient diagnosed with Friedreich's ataxia. The patient presented with bilateral cerebellar ataxia, pyramidal signs, loss of tendon reflexes, peripheral neuropathy, enlarged nerves, kyphoscoliosis, and pes cavus. Nerve biopsy revealed demyelinating neuropathy. MRI showed cervical spinal cord atrophy. The clinical diagnosis was Friedreich's ataxia based on the progressive nature of symptoms starting at age 12. The document provides figures of MRI images and references for further information on the case.
A 40-year-old female patient presented with a history of migraines. MRI scans revealed two meningioma tumors, one in the parasellar region and one in the cerebellopontine angle. The tumors appeared hyperintense on T2-weighted MRI and showed dense contrast enhancement. Based on the MRI characteristics and location of the tumors, they were diagnosed as multiple syncytial meningiomas. Syncytial meningiomas tend to appear hyperintense on T2-weighted MRI due to high cell count and microcysts.
The document describes a study that classified 21 patients with brain stem gliomas into 5 groups based on clinical features and radiological findings. Group 1 had diffuse gliomas and a relatively better prognosis. Group 2 also had diffuse gliomas but a worse prognosis. Group 3 consisted of patients with focal pontine or midbrain gliomas. Group 4 contained patients with cervicomedullary gliomas. The study analyzed each group's clinical features, treatment responses, and outcomes to better understand patterns in brain stem gliomas.
This document provides an overview of normal and sleep EEG patterns. It defines EEG and describes normal wakeful adult EEG patterns such as alpha rhythm and sleep stages. It also discusses EEG patterns in different age groups from premature infants to elderly adults. Descriptors of EEG activity and various activation procedures are explained. Common artifacts and benign variants are also summarized. The document aims to familiarize readers with the basic components of normal EEG for clinical interpretation and diagnosis.
This document provides an overview of how to conduct a neurological examination, including taking a thorough patient history and performing a physical exam. Some key points:
1. Taking a thorough history is important for localizing lesions and making a differential diagnosis. Leading questions should be asked about symptoms, onset/progression, relieving/precipitating factors, and associated symptoms.
2. Common complaints warranting detailed history include headache, dizziness/vertigo, sensory symptoms, cognitive decline, speech disorders, weakness, and visual abnormalities.
3. The physical exam follows a standardized pattern but can be tailored based on pertinent findings. It includes tests of consciousness, cognition, cranial nerves, motor function, sensory function
This document summarizes the classification and treatment of headaches. Headaches are classified as either primary/idiopathic or secondary/symptomatic. Primary headaches include tension headaches, migraines, and cluster headaches and have no underlying cause, while secondary headaches are a symptom of another condition like hypertension or meningitis. The document outlines diagnostic criteria and treatment approaches for different headache types, including acute treatment with medications and preventative treatment.
A 40-year-old female presented with headache, seizures, and altered mental status. MRI showed widespread cerebral venous thrombosis resulting in venous hypertension and congestion. This led to dilated veins and edema in the brain, seen as hyperintensities on T2-weighted MRI. The document discusses the pathophysiology of cerebral venous thrombosis, noting that increased venous pressure can cause edema, hemorrhage, and potentially infarction if pressure exceeds arterial pressure long enough. It describes three stages: initial sinus changes only, early encephalopathy with reversible edema on MRI, and later irreversible infarction if not resolved.
The document discusses butterfly tumors, which are tumors that extend bilaterally around the ventricular system like butterfly wings. These tumors can be formed by primary central nervous system (CNS) lymphomas or diffuse astrocytomas. Primary CNS lymphomas start in the subependymal microvascular system and spread centrifugally along blood vessels, while astrocytomas start focally and infiltrate locally between fibers, eventually crossing hemispheres. The document focuses on the radiological pathology of these tumors, how they progress and spread to form characteristic butterfly shapes seen on imaging. Key signs on imaging include hyperdense lesions on CT and hypointense lesions on T2-weighted MRI that enhance strongly after contrast.
This case report describes subdural empyema in a 26-year-old male patient presenting with seizures, fever, headache, and nausea. MRI scans showed multiple oval-shaped cystic lesions located between the dura mater and arachnoid mater along the falx cerebri and tentorium cerebelli, consistent with subdural empyema. Subdural empyema is a potentially life-threatening infection most often caused by bacterial spread from sinusitis or mastoiditis. It is important to promptly diagnose and treat subdural empyema surgically in addition to antibiotics due to its rapid spread and high mortality rate if left untreated.
This document discusses mesial temporal sclerosis, a common cause of temporal lobe epilepsy. It presents a case of a 23-year old woman with intractable seizures beginning with an odd smell and staring spells. Mesial temporal lobe epilepsy often begins in late adolescence/early adulthood and can be caused by hippocampal sclerosis or other lesions. Clinical features include auras and seizures characterized by automatisms or dystonic posturing localized to the affected temporal lobe. EEGs show interictal temporal spikes maximum over the affected side while ictal patterns involve rhythmic activity spreading within and between temporal lobes. MRI is used to identify hippocampal sclerosis or other lesions as the cause of seizures.
Issues in brain mapping...EEG patterns of encephalopathies and altered state ...Professor Yasser Metwally
The document discusses the usefulness of electroencephalography (EEG) in evaluating brain function and various neurological conditions. It provides details on normal EEG patterns and how they change with age. Various abnormal EEG patterns are associated with different types of encephalopathies (diffuse brain dysfunction), including triphasic waves in metabolic encephalopathy and anterior theta-delta activity with superimposed alpha in sedative drug intoxication. EEG can also help assess severity of encephalopathy and prognosis based on degree of background slowing and reactivity.
Temporal lobe epilepsy (TLE) is characterized by recurrent seizures originating from the temporal lobe. Hippocampal sclerosis, involving cell loss in the hippocampus, is the most common pathological finding in TLE. Auras occur in about 80% of temporal lobe seizures and can involve somatosensory, special sensory, autonic, or psychic symptoms. Diagnostic workup involves brain imaging like MRI and PET, as well as EEG to identify abnormalities in the temporal lobe.
Presentation1.pptx. radiological imaging of epilepsy.Abdellah Nazeer
1) Hippocampal sclerosis, characterized by hippocampal atrophy and increased signal intensity on MRI, is the most common epileptogenic abnormality found after epilepsy surgery.
2) Malformations of cortical development, including focal cortical dysplasias and heterotopias, are also common epileptogenic lesions found in surgical series, especially in patients with childhood-onset seizures.
3) In addition to structural abnormalities, low-grade gliomas and hamartomas located near the cerebral cortex are also important causes of drug-resistant epilepsy that may require surgery.
1) Radiological imaging, especially MRI, plays a key role in epilepsy diagnosis and treatment planning by identifying anatomical abnormalities.
2) Common abnormalities include hippocampal sclerosis, malformations of cortical development, tumors, and vascular malformations.
3) Hippocampal sclerosis appears on MRI as atrophy and increased signal intensity of the hippocampus. Malformations of cortical development are caused by defects in cortical development and appear as abnormalities such as lissencephaly, heterotopias, or polymicrogyria.
This lecture is all about the recognition of an abnormal EEG, its characteristics, its appearance and all about how to differentiate the abnormal activity with normal EEG background.
Epileptic encephalopathies are a group of epileptic disorders that cause cognitive and behavioral impairments beyond what would be expected from seizures alone. They typically begin early in life and are characterized by frequent seizures and abnormal EEG patterns. Common types include early myoclonic encephalopathy, Ohtahara syndrome, West syndrome, Dravet syndrome, and Lennox-Gastaut syndrome. These disorders can cause developmental delays, intellectual disabilities, and in some cases early death. Treatment aims to control seizures, though many types are highly treatment resistant.
Epileptic encephalopathies are a group of epileptic disorders that cause cognitive and behavioral impairments beyond what would be expected from seizures alone. They typically begin early in life and are characterized by frequent seizures and abnormal EEG patterns. Common types include early myoclonic encephalopathy, Ohtahara syndrome, West syndrome, Dravet syndrome, and Lennox-Gastaut syndrome. These disorders can cause developmental delays, neurological deficits, and sometimes early death if not properly treated. Management involves seizure control through medications and other therapies like the ketogenic diet.
A 50-year-old female presented with postural instability, frequent falling, and vertical gaze palsy. MRI showed selective atrophy of the midbrain, known as the "hummingbird sign", along with other findings consistent with progressive supranuclear palsy (PSP). PSP is characterized by degeneration of midbrain cells involved in eye movements and balance control, causing symptoms like vertical gaze palsy and falling. The cause is unknown but may involve tau protein aggregation in the brain. The diagnosis is clinical based on symptoms and MRI findings of midbrain atrophy.
Structural neuroimaging plays an important role in the assessment and diagnosis of different types of dementia. For Alzheimer's disease, MRI typically shows atrophy of the medial temporal lobes including the hippocampus. Vascular dementia is characterized by multiple brain infarcts visible on CT or MRI. Frontotemporal dementia demonstrates frontal and temporal lobe atrophy that can be asymmetric. Dementia with Lewy bodies may show mild generalized atrophy on MRI with occipital hypometabolism on PET. Scales like the MTA scale are used to quantify hippocampal atrophy, while MRS can detect metabolic changes in dementia. Neuroimaging thus aids in distinguishing dementia subtypes and excluding other pathological conditions.
The document discusses guidelines for using amplitude integrated EEG (aEEG) or cerebral function monitoring (CFM) to assess brain activity in newborns experiencing hypoxic-ischemic encephalopathy (HIE) or other neurological conditions. CFM can help predict outcomes from HIE by identifying abnormal brain activity in the first 6 hours after birth and detecting neonatal seizures. The document provides guidance on proper electrode placement and interpreting CFM readings to distinguish normal and abnormal brain activity patterns while avoiding common artifacts.
Neurology 2nd investigation of neurological diseaseRamiAboali
This document discusses various neurological investigations and presenting problems. It provides details on neuroimaging techniques like CT, MRI, EEG and lumbar puncture. It also describes nerve conduction studies and evoked potentials. Common presenting problems covered include syncope, coma, and alterations in behavior like delirium and dementia. Causes, diagnosis, and management are discussed for syncope and coma. The document is a reference for neurology that outlines different testing and clinical presentations.
This document provides an overview of magnetic resonance imaging (MRI) and several case examples demonstrating its clinical applications. The key points covered include:
- MRI works by detecting tiny movements of protons in tissue when exposed to magnetic fields. Different sequences like T1 and T2 provide different tissue contrasts.
- Brain MRI is very useful for detecting lesions and assessing anatomy without radiation. Several brain cases demonstrate common conditions like tuberculoma, multiple sclerosis, and mitochondrial disease.
- Spine MRI is now the primary imaging method for evaluating the spine. Examples show common spinal pathologies and the importance of classification of disc abnormalities.
- MRI has many clinical uses beyond the brain and spine, such as cardiac imaging
The document discusses various tests used to investigate neurological diseases, including imaging tests like CT, MRI, X-rays; lumbar puncture to examine cerebrospinal fluid; nerve conduction and electromyography tests; evoked potentials; and specialized blood and biopsy tests. CT is useful for detecting tumors, hemorrhages, and fractures but has limitations. MRI provides better soft tissue contrast and avoids radiation. Lumbar puncture examines CSF for signs of infection or inflammation.
This document discusses somatosensory evoked potentials (SEPs), which are electrical signals generated in the nervous system in response to sensory stimuli. SEPs reflect the activation of neural structures along somatosensory pathways. They are recorded using electrodes on the scalp and spine in response to electrical stimulation of peripheral nerves. SEP waves are labeled according to their polarity and latency. Clinical uses of SEPs include evaluating peripheral nerves and central somatosensory pathways, localizing lesions, and monitoring patients in intensive care and during surgery. Abnormal SEPs can indicate disorders of the peripheral or central nervous system.
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The document discusses the benefits of exercise for mental health. It states that regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help alleviate symptoms of mental illness.
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This document discusses the radiological pathology of seizure disorders. It describes various developmental anomalies, neoplasms, infections, immune-mediated disorders, cerebrovascular diseases, and trauma that can cause seizures. Specific conditions mentioned include cortical dysplasia, tuberous sclerosis, Sturge-Weber syndrome, neuronal migration disorders, vascular malformations, infections, and immune-mediated Rasmussen's encephalitis. The document provides detailed descriptions of the histopathological findings and MRI/CT appearances of different lesions that can underlie seizure disorders.
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A 57-year-old male patient presented with left lower limb weakness that had progressed over three months. MRI images showed bilateral, symmetrical lesions in the posterior parieto-occipital white matter, which had scalloped margins and did not enhance or cause mass effect. Based on the clinical presentation and MRI findings, the patient was diagnosed with progressive multifocal leukoencephalopathy (PML), a demyelinating disease caused by JC virus reactivation that predominantly affects immunocompromised individuals. PML lesions are typically multifocal and located in the white matter of the brain, most often in the parieto-occipital region.
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chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
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GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
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Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
Know the difference between Endodontics and Orthodontics.
Issues in brainmapping...EEG in brain tumors
1. Version 15 A Monthly Publication presented by Professor Yasser Metwally November 2009
INTRODUCTION
Until the past 3 decades, localization of brain tumors and other focal lesions was difficult. Neuroimaging techniques consisted of skull x-rays,
which were usually negative, and pneumoencephalograms, which were invasive, painful, and often uninformative. In 1936, Walter, who
introduced the term “delta waves,” first identified the association between localized slow waves on EEG and tumors of the cerebral
hemispheres. This established EEG as an important tool for localizing brain tumors. For the next 4 decades electroencephalographers
mounted an enormous effort to improve accuracy of localization and to seek clues to underlying pathologic processes.
Experience has shown EEG to be somewhat reliable in localizing lesions involving superficial accessible portions of the cerebral hemispheres,
though it is of limited value in deep-seated lesions, especially posterior fossa tumors. The role of EEG in detecting focal cerebral disturbances
has undergone a significant change since the development of CT scan and MRI. Today EEG is primarily complementary to these studies and
is used mainly for evaluating functional changes in the patient’s condition. It demonstrates aspects of brain physiology that are not reflected in
structural neuroimaging. Functional neuroimaging techniques, such as positron emission tomography (PET), single-photon emission
computed tomography (SPECT), and functional MRI (fMRI), can exhibit physiologic changes but not with the temporal resolution of EEG.
Furthermore, EEG provides the only continuous measure of cerebral function over time.
This article reviews the major EEG changes that occur with different brain tumors, as determined by location, histologic type, associated
complications, and surgical and nonsurgical treatments.
TYPES OF EEG ABNORMALITIES ASSOCIATED WITH BRAIN TUMORS
EEG abnormalities in brain tumors depend on the stage at which the patient presents for evaluation. EEG changes observed with tumors result
mainly from disturbances in bordering brain parenchyma, since tumor tissue is electrically silent (with the possible exception of tumors
containing neuronal elements, such as gangliogliomas). For this reason, EEG localization often is misleading, although lateralization is generally
reliable.
The following are common findings:
Polymorphic delta activity (PDA)
Intermittent rhythmic delta activity (IRDA)
Diffuse or localized theta activity
Localized loss of activity over the area of the tumor
Asymmetric beta activity
Disturbance of the alpha rhythm
Spikes, sharp waves, or spike-wave discharges
Activation procedures are usually of limited value in patients with tumors, although hyperventilation occasionally can accentuate focal slowing.
Asymmetries of photic driving can be useful at times, although they also can be misleading.
Slow Wave Activity
Focal delta activity is the classic electrographic sign of a local disturbance in cerebral function. A structural lesion is strongly suggested if the
delta activity is continuously present; shows variability in waveform amplitude, duration, and morphology (polymorphic); and persists during
changes in physiologic states, such as sleep or alerting procedures. When focal delta is found without a corresponding imaging abnormality, it is
usually in the setting of acute seizures (especially postictally), nonhemorrhagic infarction, or trauma.
Clinical and experimental observations indicate that PDA results primarily from lesions affecting cerebral white matter; involvement of
superficial cortex is not essential, and lesions restricted to the cortical mantle generally do not produce significant delta activity. Functional
deafferentation of cortex likely is critical.
Delta activity that fails to persist into sleep or attenuates significantly with arousal or eye opening is less indicative of structural pathology, as is
rhythmic or sinusoidal delta. The latter usually occurs intermittently and is termed IRDA. It is usually bilateral and of high amplitude and is
2. typically maximal occipitally (OIRDA) in children and frontally (FIRDA) in adults. Unlike PDA, IRDA increases in drowsiness and attenuates
with arousal. IRDA often is observed without structural pathology, as in metabolic encephalopathies, but it also can occur with diencephalic or
other deep lesions; in this situation, an amplitude asymmetry can be present, with higher amplitude ipsilateral to the lesion.
As in other clinical settings, theta activity is indicative of less severe localized or diffuse dysfunction than delta activity and is observed more
commonly with functional disturbances than with structural disturbances. When unaccompanied by delta activity, theta is less likely to indicate a
lesion that produces a focal neurologic deficit or seizures.
Localized Loss and Asymmetries of Background Activity
Since tumor tissue probably does not generate electrical activity detectable with conventional recording techniques, electrical silence is the best
localizing sign of a cerebral tumor. However, it is a rare finding, occurring only when the tumor involves significant cortical areas with minimal
subcortical disruption. Incomplete loss of activity, especially faster normal rhythms, is observed more commonly and is diagnostically helpful.
Alpha rhythm
By the time the patient presents with focal or diffuse neurologic symptoms and signs, disturbance of the alpha rhythm may be present. Slowing of
the alpha rhythm ipsilateral to a tumor is more common and significant than asymmetry of amplitude. However, disturbance of alpha rhythm
depends on the site of the tumor. The more posterior the location, the more the alpha tends to be slowed, impersistent, or disturbed by admixed
theta waves. The alpha rhythm also may fail to block to eye opening on the side of the neoplasm (ie, Bancaud phenomenon).
Beta activity
Abnormalities of beta activity usually are limited to voltage asymmetries. To be considered unequivocally abnormal, a persistent amplitude
difference of one third or greater (expressed as a fraction of the higher voltage) should be present. Diminished beta activity results either from
cortical dysfunction, as in parenchymal tumors, or from an increase in resistance of the medium-separating cortex from scalp-recording electrodes,
as in meningiomas or subdural collections. Focally increased beta activity usually is associated with a skull defect.
Interictal Epileptiform Discharges
Isolated discharges
Spikes, sharp waves, or spike-wave complexes occurring with consistent localization are observed uncommonly early in the course of brain tumors.
In one study predating the CT scan era, such discharges appeared with only 3% of gliomas and metastatic tumors at the time of craniotomy.
However, they were more common either as early findings of slowly growing neoplasms associated with seizures or later after focal slowing had
developed.
Periodic lateralized epileptiform discharges
Patients with tumors may exhibit periodic lateralized epileptiform discharges (PLEDs) at times, particularly after a series of seizures. In a study of
282 patients with typical PLEDs, tumor was present in 18%. Most patients with this EEG finding have had or will have seizures, if they are
observed sufficiently closely and persistently; the pattern likely represents a transitional state between ictal and interictal epileptiform discharges.
Aggressiveness of treatment depends in part on whether the discharges are resolving (becoming less sharp, more localized, and further apart) or
the opposite.
Seizure patterns
When electrographic seizures are recorded during a routine EEG, suspect status epilepticus. Clinical accompaniments may be subtle, as in aphasic
or other forms of nonconvulsive status, particularly when the patient’s baseline condition has been compromised by the tumor, its treatment, or
complications.
EEG CHANGES IN TUMORS BY LOCATION
Since EEG reflects activity of cortical neurons, hemispheric tumors affect EEG most consistently and prominently. In older studies, a normal EEG
occurred in approximately 5% of hemispheric, 25% of deep or basal, and 25% of infratentorial tumors. The overall figure now may be 50% or
higher, given the earlier diagnosis allowed by modern neuroimaging. Location is an important determinant of the likelihood and nature of EEG
abnormalities.
Frontal Lobe Tumors
Frontal lobe tumors characteristically cause focal PDA, which accurately localizes the lesion.
In approximately one third of patients, slow waves are bilateral and may be IRDA rather than PDA. This occurs most often when deep structures
such as the corpus callosum are involved (butterfly glioma).
3. IRDA is more frequent with frontal tumors than with tumors in other hemispheric locations, even in children in whom the IRDA is often
maximal occipitally (OIRDA).
The slow wave abnormality may be only in the theta range, particularly in small, slowly growing tumors.
The alpha rhythm usually is preserved, although it may be disrupted with large lesions.
Parasagittal tumors, particularly meningiomas, may cause decreased beta activity on the side of the tumor or runs of ipsilateral alpha and theta
activity.
Sharp waves and spikes are most likely in slow-growing neoplasms and may be bilateral; occasionally, frontally predominant spike-wave
complexes mimicking those of idiopathic epilepsies may be produced.
Temporal Lobe Tumors
Temporal gliomas are generally the easiest to localize on EEG, since PDA occurs over the tumor site in more than 80% of patients. Tumors in
other locations, such as the thalamus, also may produce temporal delta; however, focal delta is more reliably localizing when background rhythms
also are attenuated.
Anterior temporal
When tumors are in this location, a well-preserved alpha rhythm occurs.
PDA is well localized.
EEG from the contralateral hemisphere is often virtually normal.
Since these tumors often are associated with seizures, they may demonstrate interictal epileptiform discharges. These may be identical to those
associated with nonneoplastic lesions such as mesial temporal sclerosis, especially when the tumor is located medially, as is often the case
with very slow-growing tumors, such as gangliogliomas and dysembryoplastic neuroepithelial tumors.
Posterior temporal
Tumors in this location are characterized by PDA and usually disturbance of the ipsilateral alpha rhythm.
Slowing or disorganization of the alpha rhythm with intermixed theta is present.
Occasionally, alpha amplitude is decreased markedly rather than slowed.
Parietal Lobe Tumors
Tumors in this region less often produce localized slowing; PDA usually is lateralized but often not clearly localized. When phase reversals
are present, they may be temporal or frontal rather than parietal.
PDA is often slow (<2 Hz), but it is usually of lower amplitude than with frontal or temporal tumors.
The alpha background generally is disturbed either ipsilaterally or bilaterally.
Theta rather than delta activity may occur in meningiomas, low-grade gliomas, and small metastases.
In centroparietal tumors, mu rhythms may be attenuated ipsilaterally but occasionally may be more persistent and of higher amplitude.
Since seizures are common in patients with tumors in perirolandic areas, ipsilateral epileptiform discharges may be present; at times they may
be difficult to distinguish from mu, especially after craniotomy.
Occipital Lobe Tumors
Most occipital gliomas produce focal changes, especially PDA, which spreads variably to more anterior and contralateral locations. Occipital
meningiomas, mainly of the tentorium, can cause more focal EEG changes.
The background alpha rhythm is rarely normal and may be impaired either ipsilaterally or bilaterally.
Interictal epileptiform discharges are rare.
Deep Hemispheric Tumors
Deep hemispheric tumors include tumors impinging on the lateral and third ventricle and surrounding structures, including the diencephalon,
basal ganglia, and corpus callosum. Neuroimaging has led to earlier diagnosis of smaller tumors that may be associated with normal EEGs.
When abnormalities are observed, the following apply:
The typical EEG finding is IRDA. This finding classically has been associated with hydrocephalus or increased intracranial pressure, but this
assumption may be incorrect, since IRDA is uncommon in hydrocephalus of nonneoplastic origin and is not present in benign intracranial
hypertension.
PDA typically does not occur, although asymmetric IRDA is relatively common.
Especially in older patients, rhythmic delta may be more continuous than intermittent.
Alpha rhythm and sleep spindles may be disrupted ipsilateral to the lesion.
Epileptiform discharges are very rare
4. Intraventricular and Sellar Tumors
Lateral ventricle (ependymoma, meningioma)
EEG may exhibit PDA over the ipsilateral temporal lobe.
Theta and sharp waves may be present temporally.
Third ventricle (colloid cyst, epidermoid, craniopharyngioma)
EEG is usually normal unless the lesion is large.
Slowing may be bifrontal or diffuse.
Runs of theta may be observed.
Sellar region
EEG is usually normal
If present, slowing is usually bitemporal.
Infratentorial tumors
Brain stem and cerebellum
EEG is more often abnormal in children.
If present, slowing is most often posterior and bilateral.
IRDA may be observed, especially if hydrocephalus is present.
Cerebellopontine angle (acoustic neuroma)
EEG is usually normal, especially with small tumors.
When present, slowing is usually temporal or temporal occipital.
Slowing is often intermittent and usually but not always ipsilateral; it may be bilateral or even predominantly contralateral.
TUMOR TYPE AND EEG
EEG patterns are not specific for tumor pathology, but some general correlations exist.
Slowly growing extra-axial tumors, such as meningiomas, produce the mildest EEG disturbances, whereas rapidly growing intraaxial
tumors, such as glioblastomas, cause the most marked abnormalities.
Benign intraaxial tumors, such as astrocytomas or oligodendrogliomas, are intermediate in their effects on the EEG.
Interictal discharges most commonly are observed initially in slowly growing tumors and often are observed later in the course of higher
grade lesions.
Meningiomas
Being extraaxial, meningiomas compress the brain but cause little destruction of brain tissue. Therefore, meningiomas of the anterior or middle
cranial fossa, unless large, infrequently alter EEGs. Convexity meningiomas are more likely to cause EEG changes. With rolandic or
parasagittal meningiomas, common EEG changes include the following:
Focal theta activity
FIRDA
Diminished, or less often, augmented beta activity
Focal PDA that is usually low in amplitude (50-60 mV), intermittent, and misleadingly prominent in temporal derivations
Epileptiform discharges observed in as many as 45% of patients
Gliomas
Slowly growing gliomas such as oligodendrogliomas and fibrillary astrocytomas (excluding tumors of deep structures) often can be distinguished
from the more rapidly growing anaplastic astrocytoma and glioblastoma multiforme.
With the more benign tumors, which comparatively are circumscribed, the abnormalities tend to be localized and within the theta
range.
5. In the rapidly growing tumors, relatively more overall abnormality is present, and the background (particularly the alpha rhythm) is more
impaired and disorganized.
Glioblastomas produce the most widespread, slowest (often 1 Hz or less), and largest (100-200 mV) delta waves. These tumors cause
prominent PDA, with marked alteration of background rhythms. Also, the high incidence of necrosis makes “flat PDA” (low-amplitude
slow delta with diminished fast activity) more likely.
Indolent gliomas commonly cause seizures, and epileptiform activity may appear before significant slowing occurs. Later, delta appears,
often intermittently and at 2-3 Hz. Still later, focal PDA becomes persistent.
Metastases
Metastatic tumors to the brain occur commonly with carcinomas of lung, kidney, and breast and with melanomas and chorionic carcinomas. When
metastases are present bilaterally, slowing often appears diffuse, although it is often asymmetric; slowing from multiple bilateral lesions is often
difficult to distinguish from a toxic-metabolic disturbance. Meningeal carcinomatosis usually causes changes that correlate with the clinical
situation; when deposits are widespread and cause an encephalopathy, slowing is usually diffuse.
Isolated metastases usually cause less prominent abnormalities than gliomas of similar size and location. Slow waves show higher frequency,
lower amplitude, and less persistence than with high-grade gliomas, and normal background rhythms are more likely to be preserved.
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