This document discusses the importance and implementation of continuous EEG monitoring in intensive care units. It notes that EEG can detect brain ischemia earlier than clinical signs, monitor for nonconvulsive seizures, and provide early prognostic information. Successful ICU/cEEG programs require collaboration between neurophysiologists, neurointensivists, ICU staff and others. Regular training of ICU staff is needed so they can recognize normal and abnormal waveforms and ensure monitoring is available 24/7. Teamwork and institutional support are essential for effective ICU/cEEG monitoring.
This document summarizes an electrophysiological study before pacemaker implantation. It includes 5 points: 1) Establish diagnosis, 2) Assist in setting pacemaker parameters, 3) Confirm efficacy of ATP therapy, 4) Assist in future troubleshooting, and 5) Provide additional information. It then presents several case studies of patients undergoing evaluation and pacemaker implantation. The document discusses techniques for electrophysiological studies and guidelines for permanent pacing in chronic bifascicular block.
This case report describes 8 patients presenting with sensory Guillain-Barré syndrome (GBS). The key findings were:
1) Acute onset of symmetric sensory loss, peaking within 4 weeks
2) Diminished or absent reflexes
3) Normal motor strength
4) CSF albuminocytologic dissociation in patients tested within 4 weeks
5) Nerve conduction studies showing evidence of demyelination
All patients had a monophasic course and good recovery, confirming the existence of a sensory variant of GBS.
This document summarizes information presented at a conference on immune-mediated neuropathies and treatment options for patients who do not respond to conventional therapies. It discusses various subtypes of chronic inflammatory demyelinating polyneuropathy (CIDP) and provides treatment guidelines. For patients who do not respond initially, it recommends reconsidering the diagnosis or trying immunosuppressant drugs, and more research is needed to determine their effectiveness for CIDP.
A 41-year-old man presented to the emergency department with a sudden onset severe headache, diplopia, photophobia, nausea, vomiting and fever. Physical examination revealed right eye ptosis and cranial nerve palsies. Imaging showed a pituitary mass with hemorrhage consistent with pituitary tumor apoplexy. The patient underwent surgery and hormone replacement therapy. MRI is the best test to diagnose pituitary apoplexy but may be preceded by CT to screen for hemorrhage.
Catheter ablation of premature ventricular complexes (PVCs) is an effective treatment when disabling symptoms or ectopy-induced cardiomyopathy are present in patients refractory to pharmacological therapy. When PVCs originate close to His bundle, radiofrequency ablation is burdened by unacceptable risk of conduction pathways damage or atrio-ventricular block. Here we report a case of a patient with highly symptomatic ventricular ectopy originating close to His bundle undergoing successfull cathetercryoablation.
1) The study aimed to identify the sensitivity and specificity of J-waves and ST-segment changes on ECGs in diagnosing penetrating cardiac injuries in stable trauma patients.
2) They found that J-waves had a sensitivity of 44% and specificity of 85% in detecting cardiac injuries, while ST-segment changes were less specific with a sensitivity of 67% and specificity of 54%.
3) The presence of a J-wave on ECG was a significant indicator of a hemopericardium and suggested further investigation and management at a trauma center may be needed.
1. The document discusses the clinical use of a portable head CT scanner called CereTom that can scan patients at their bedside. Between 2006-2009, 3421 portable CT scans were performed, with 95.8% in the neuroscience ICU.
2. Scans were used to guide treatment for conditions like traumatic brain injury, hemorrhage, and stroke. Quantitative CBF data from scans helped guide decisions around blood pressure management and other physiological variables.
3. Portable CT allowed scanning of critically ill patients without the risks of moving them, and provided rapid anatomical and physiological data to guide critical care decisions at the patient's bedside.
La conduzione del nervo surale dorsale in pazienti con carenza di vitamina B1...MerqurioEditore_redazione
This study investigated peripheral neuropathy in vitamin B12 deficient patients with megaloblastic anemia using dorsal sural nerve conduction studies and tibial sensory-evoked potentials. Dorsal sural nerve responses were absent in over half of patients but only one third had abnormalities on conventional nerve conduction studies. Patients with recordable dorsal sural nerves had prolonged latencies, reduced amplitudes, and slower conduction velocities compared to controls, suggesting dorsal sural nerve conduction is more sensitive for detecting early neuropathy. Over 70% of patients showed evidence of myelopathy on tibial sensory-evoked potentials and neurological examination.
This document summarizes an electrophysiological study before pacemaker implantation. It includes 5 points: 1) Establish diagnosis, 2) Assist in setting pacemaker parameters, 3) Confirm efficacy of ATP therapy, 4) Assist in future troubleshooting, and 5) Provide additional information. It then presents several case studies of patients undergoing evaluation and pacemaker implantation. The document discusses techniques for electrophysiological studies and guidelines for permanent pacing in chronic bifascicular block.
This case report describes 8 patients presenting with sensory Guillain-Barré syndrome (GBS). The key findings were:
1) Acute onset of symmetric sensory loss, peaking within 4 weeks
2) Diminished or absent reflexes
3) Normal motor strength
4) CSF albuminocytologic dissociation in patients tested within 4 weeks
5) Nerve conduction studies showing evidence of demyelination
All patients had a monophasic course and good recovery, confirming the existence of a sensory variant of GBS.
This document summarizes information presented at a conference on immune-mediated neuropathies and treatment options for patients who do not respond to conventional therapies. It discusses various subtypes of chronic inflammatory demyelinating polyneuropathy (CIDP) and provides treatment guidelines. For patients who do not respond initially, it recommends reconsidering the diagnosis or trying immunosuppressant drugs, and more research is needed to determine their effectiveness for CIDP.
A 41-year-old man presented to the emergency department with a sudden onset severe headache, diplopia, photophobia, nausea, vomiting and fever. Physical examination revealed right eye ptosis and cranial nerve palsies. Imaging showed a pituitary mass with hemorrhage consistent with pituitary tumor apoplexy. The patient underwent surgery and hormone replacement therapy. MRI is the best test to diagnose pituitary apoplexy but may be preceded by CT to screen for hemorrhage.
Catheter ablation of premature ventricular complexes (PVCs) is an effective treatment when disabling symptoms or ectopy-induced cardiomyopathy are present in patients refractory to pharmacological therapy. When PVCs originate close to His bundle, radiofrequency ablation is burdened by unacceptable risk of conduction pathways damage or atrio-ventricular block. Here we report a case of a patient with highly symptomatic ventricular ectopy originating close to His bundle undergoing successfull cathetercryoablation.
1) The study aimed to identify the sensitivity and specificity of J-waves and ST-segment changes on ECGs in diagnosing penetrating cardiac injuries in stable trauma patients.
2) They found that J-waves had a sensitivity of 44% and specificity of 85% in detecting cardiac injuries, while ST-segment changes were less specific with a sensitivity of 67% and specificity of 54%.
3) The presence of a J-wave on ECG was a significant indicator of a hemopericardium and suggested further investigation and management at a trauma center may be needed.
1. The document discusses the clinical use of a portable head CT scanner called CereTom that can scan patients at their bedside. Between 2006-2009, 3421 portable CT scans were performed, with 95.8% in the neuroscience ICU.
2. Scans were used to guide treatment for conditions like traumatic brain injury, hemorrhage, and stroke. Quantitative CBF data from scans helped guide decisions around blood pressure management and other physiological variables.
3. Portable CT allowed scanning of critically ill patients without the risks of moving them, and provided rapid anatomical and physiological data to guide critical care decisions at the patient's bedside.
La conduzione del nervo surale dorsale in pazienti con carenza di vitamina B1...MerqurioEditore_redazione
This study investigated peripheral neuropathy in vitamin B12 deficient patients with megaloblastic anemia using dorsal sural nerve conduction studies and tibial sensory-evoked potentials. Dorsal sural nerve responses were absent in over half of patients but only one third had abnormalities on conventional nerve conduction studies. Patients with recordable dorsal sural nerves had prolonged latencies, reduced amplitudes, and slower conduction velocities compared to controls, suggesting dorsal sural nerve conduction is more sensitive for detecting early neuropathy. Over 70% of patients showed evidence of myelopathy on tibial sensory-evoked potentials and neurological examination.
The patient experienced a severe episode of hypotension and desaturation while waiting to undergo an MRI exam. This was diagnosed as anaphylactic shock. The patient has a history of polytrauma but no known drug allergies. Treatment included epinephrine, fluids, corticosteroids, and being admitted to the ICU for monitoring and support. The trigger for the anaphylaxis is unknown but occurred in the context of ongoing medical care for the patient's injuries. Diagnosing anaphylaxis can be challenging and errors are common even for experienced anesthesiologists when encountering simulated cases.
The document summarizes the role and responsibilities of an Assistant Professor of Surgery who directs a Functional and Restorative Neurosurgery program at a university. The summary includes details on the interdisciplinary team involved in deep brain stimulation procedures and an overview of the four stages of the DBS treatment process.
This document summarizes research on diverse mechanisms of blast-induced neurotrauma in rat models. It finds that exposure to a single "composite" blast, which includes head acceleration, results in cerebrovascular damage, astrocyte activation (glyosis), and neuronal injury. A single "primary" blast exposure instigated predominantly systemic/vascular changes and glyosis. The positional orientation of the animal relative to the shock wave influences whether a composite or primary blast is experienced. Responses depend on the type and magnitude of blast exposure.
1) Two Mexican sisters were found to have choreoacanthocytosis (CHAC), a rare hereditary neurodegenerative syndrome.
2) The older sister first developed symptoms at age 32, including chorea, lip and tongue biting, and weight loss. The younger sister developed similar symptoms starting at age 45.
3) Genetic testing revealed both sisters were homozygous for the same frameshift mutation in the VPS13A gene known to cause CHAC. This confirms the diagnosis and suggests their parents were consanguineous.
1. The study evaluated delayed rises in intracranial pressure (ICP) in patients with head injuries.
2. Of the 21 patients, 6 patients experienced delayed rises in ICP after initially normal readings, with ICP levels ranging from 21-40 cm H2O.
3. Patients with effaced cisterns on initial CT scans and delayed rises in ICP had the worst outcomes, with high mortality and disability rates.
This document discusses different types of evoked potentials, including visual evoked potentials (VEP), brainstem auditory evoked potentials (BAEP), sensory evoked potentials, and motor evoked potentials. It provides information on the objectives, electrical activity in the brain, primary and secondary responses, factors that influence the potentials, and clinical applications. The VEP section specifically addresses anatomy, physiology, waveform, methods of recording, abnormalities, and use in assessing visual pathway integrity. BAEP is described as assessing hearing in infants and localizing brainstem lesions. Sensory evoked potentials evaluate sensory pathway intactness while motor evoked potentials are recorded from muscles to diagnose neurological diseases.
Genetics Screening Of Human Cardiac Ryanodine Receptor Mutations In Ion ChannelTaruna Ikrar
1. The study analyzed 83 Japanese patients with various arrhythmic disorders including long-QT syndrome, Brugada syndrome, idiopathic ventricular fibrillation, arrhythmogenic right ventricular cardiomyopathy, and catecholaminergic polymorphic ventricular tachycardia (CPVT).
2. Genetic screening revealed 3 distinct mutations in the cardiac ryanodine receptor gene (RyR2) among 4 families with CPVT, representing a 75% incidence of RyR2 mutations in CPVT patients.
3. However, no RyR2 mutations were found in patients with long-QT syndrome, Brugada syndrome, idiopathic ventricular fibrillation, or arrhythmogenic right ventricular
This document summarizes a study on screening first-degree relatives of patients with bicuspid aortic valve. The study found a prevalence of bicuspid aortic valve of 5.9% in first-degree relatives screened, compared to 0.5-1% in the general population. Screening 184 first-degree relatives of 60 probands with bicuspid aortic valve identified 11 relatives with aortic valve abnormalities. The study concludes that echocardiographic screening of first-degree relatives is useful for identifying asymptomatic cases of bicuspid aortic valve.
This document summarizes the physiology and pharmacology of anticholinesterase drugs. It discusses the structure and function of nicotinic acetylcholine receptors and how conditions like trauma or disease can upregulate or downregulate these receptors. It describes how anticholinesterase drugs like neostigmina and edrophonium work by inhibiting acetylcholinesterase and preventing the breakdown of acetylcholine, allowing it to remain active in synaptic regions for longer. The document discusses variables like drug half-lives and clearance rates of various anticholinesterase medications. It also addresses factors that influence the antagonism of neuromuscular blocking drugs like the depth of block at time of administration and presence of inhal
ECoG involves placing electrodes directly on the surface of the exposed brain to record electrical activity with greater spatial resolution than traditional EEG. The document discusses using ECoG to monitor spreading depolarizations, waves of sustained neuronal depolarization that can propagate through brain tissue. Studies found spreading depolarizations commonly occur after traumatic brain injury and are associated with worse outcomes. ECoG may help guide individualized treatment by continuously monitoring these depolarizations in neuroICU patients.
The document discusses the history and development of implantable cardioverter defibrillators (ICDs) from their introduction in 1980 through dual chamber ICDs in 1997 and leadless ICDs in 2012. It then summarizes several major clinical trials that demonstrated the mortality benefits of ICD therapy in both primary and secondary prevention of sudden cardiac death. These trials showed reductions in overall mortality ranging from 20-55% and reductions in arrhythmic mortality ranging from 28-75% with ICD therapy.
This document discusses various techniques for monitoring patients in the intensive care unit (ICU), including electroencephalography (EEG), somatosensory evoked potentials (SSEPs), brain oxygen monitoring, intracranial pressure (ICP) monitoring, and cerebral blood flow monitoring using transcranial Doppler ultrasound. It provides examples of how these monitoring techniques can be used to detect seizures, brain injury, vasospasm, and other conditions in ICU patients.
Dr. sarah weckhuysen kcnq2 Cure summit parent track learn more at kcnq2cure.orgscottyandjim
This document discusses KCNQ2 gene mutations which can cause different epilepsy phenotypes from benign familial neonatal seizures (BFNS) to more severe early-onset epileptic encephalopathy. It describes the discovery of KCNQ2 mutations in BFNS in 1998 and more recent findings of de novo missense mutations in 10% of patients with treatment-resistant neonatal epileptic encephalopathy. These mutations have a dominant-negative effect on channel function and cause neuronal hyperexcitability. The document also reviews other ion channel mutations associated with epilepsy phenotypes along a spectrum, such as SCN1A mutations which can cause GEFS+ or more severe Dravet syndrome.
This document discusses using optic nerve sheath diameter (ONSD) measurements via ultrasound as a tool to assess increased intracranial pressure (ICP). It provides background on ONSD anatomy and evidence that ONSD changes mimic ICP changes. Studies show ONSD has high sensitivity and specificity for detecting elevated ICP compared to invasive monitoring. The document proposes a prospective study measuring ONSD in patients with conditions like end-stage liver disease, end-stage renal disease, and hypertensive crises to see if ONSD decreases after treatment and normalize, indicating reduced ICP. It suggests ONSD could help predict complications like dialysis disequilibrium syndrome.
1) Intraoperative neurophysiological monitoring utilizes evoked potentials and EEG to minimize morbidity from surgical manipulation and preserve nervous system function. Monitoring modalities assess nervous system blood flow, oxygenation, metabolism, and direct function.
2) Transcranial Doppler ultrasound, jugular venous oximetry, and near infrared spectroscopy noninvasively monitor cerebral blood flow and oxygenation. Microdialysis assesses cerebral metabolism by analyzing extracellular fluid.
3) Evoked potentials including somatosensory, motor, auditory, and visual evaluate specific neural pathways, while spontaneous EEG assesses global brain activity intraoperatively.
Advances in neuro anesthesia monitoringWesam Mousa
The document discusses various techniques for monitoring the brain during anesthesia to prevent neurological insults. It describes electroencephalography (EEG) techniques like raw EEG, bispectral index, and entropy which can detect cerebral ischemia. It also discusses evoked potentials like somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) using electrical stimulation to assess spinal cord and brain function. Additional monitoring methods covered are intracranial pressure (ICP), cerebral blood flow (CBF), brain oxygenation, and electromyography (EMG) for nerve function. The document emphasizes multimodal monitoring as the gold standard to reduce intraoperative neurological injury.
The document discusses evaluation and testing for syncope. It notes that history and physical exam are the best initial tools to determine etiology. Certain historical clues can suggest neurally-mediated, orthostatic, or seizure-related causes. Predictors of cardiac syncope include absence of pre-syncope, duration of loss of consciousness, and recovery pattern. Recommended tests include ECG, telemetry, Holter monitor, event recorder, and implantable loop recorder. ILR has a high diagnostic yield of 65-90% and may be useful when initial tests are non-diagnostic.
1) Status epilepticus refers to prolonged or continuous seizure activity lasting more than 5 minutes. It is a medical emergency that can cause neuronal damage the longer it persists.
2) Treatment involves controlling airway and vital signs, administering glucose and thiamine, performing diagnostic tests, and starting anticonvulsant drug therapy.
3) First line drug therapy includes lorazepam or diazepam followed by phenytoin or fosphenytoin. If seizures continue, additional doses of these drugs or alternative drugs like phenobarbital are given.
This document discusses status epilepticus (SE), including:
- Definitions and types of SE such as convulsive SE, nonconvulsive SE, and acute repetitive seizures.
- Characteristics of generalized convulsive SE.
- Incidence and mortality rates of SE which increase with age.
- Main causes of SE such as low antiepileptic drug levels, cerebrovascular accidents, anoxia/hypoxia, and metabolic disturbances.
- Guidelines for the management of SE including initiating treatment with benzodiazepines like lorazepam or diazepam, followed by antiepileptic drugs like fosphenytoin, phenytoin,
EEG measures the electrical activity of the brain through electrodes placed on the scalp. It can detect different wave patterns associated with different brain states. Evoked potentials involve stimulating a sensory pathway and measuring the electrical response along the pathway. This allows localization of lesions. Somatosensory evoked potentials involve stimulating a peripheral nerve like the median nerve and measuring the response along the pathway to detect spinal cord or brain injuries. Auditory evoked potentials involve measuring the brainstem response to a click stimulus to detect acoustic neuromas or other posterior fossa lesions. Both evoked potentials and EMG monitoring are used during surgery to detect injuries.
Post-traumatic epilepsy (PTE) is defined as recurrent seizures occurring after traumatic brain injury (TBI). TBI accounts for 10-20% of epilepsy cases. Risk factors for early PTE include GCS <10, intracranial hematoma, and seizures within 24 hours of injury. Risk factors for late PTE include penetrating injury, intracranial hematoma, early PTE, and age over 35. Temporal lobes are the most common localization. Standard anticonvulsants are used to treat established PTE but prophylaxis is ineffective at preventing late PTE. Surgery may be considered for refractory late PTE if the seizure focus is well-localized.
The patient experienced a severe episode of hypotension and desaturation while waiting to undergo an MRI exam. This was diagnosed as anaphylactic shock. The patient has a history of polytrauma but no known drug allergies. Treatment included epinephrine, fluids, corticosteroids, and being admitted to the ICU for monitoring and support. The trigger for the anaphylaxis is unknown but occurred in the context of ongoing medical care for the patient's injuries. Diagnosing anaphylaxis can be challenging and errors are common even for experienced anesthesiologists when encountering simulated cases.
The document summarizes the role and responsibilities of an Assistant Professor of Surgery who directs a Functional and Restorative Neurosurgery program at a university. The summary includes details on the interdisciplinary team involved in deep brain stimulation procedures and an overview of the four stages of the DBS treatment process.
This document summarizes research on diverse mechanisms of blast-induced neurotrauma in rat models. It finds that exposure to a single "composite" blast, which includes head acceleration, results in cerebrovascular damage, astrocyte activation (glyosis), and neuronal injury. A single "primary" blast exposure instigated predominantly systemic/vascular changes and glyosis. The positional orientation of the animal relative to the shock wave influences whether a composite or primary blast is experienced. Responses depend on the type and magnitude of blast exposure.
1) Two Mexican sisters were found to have choreoacanthocytosis (CHAC), a rare hereditary neurodegenerative syndrome.
2) The older sister first developed symptoms at age 32, including chorea, lip and tongue biting, and weight loss. The younger sister developed similar symptoms starting at age 45.
3) Genetic testing revealed both sisters were homozygous for the same frameshift mutation in the VPS13A gene known to cause CHAC. This confirms the diagnosis and suggests their parents were consanguineous.
1. The study evaluated delayed rises in intracranial pressure (ICP) in patients with head injuries.
2. Of the 21 patients, 6 patients experienced delayed rises in ICP after initially normal readings, with ICP levels ranging from 21-40 cm H2O.
3. Patients with effaced cisterns on initial CT scans and delayed rises in ICP had the worst outcomes, with high mortality and disability rates.
This document discusses different types of evoked potentials, including visual evoked potentials (VEP), brainstem auditory evoked potentials (BAEP), sensory evoked potentials, and motor evoked potentials. It provides information on the objectives, electrical activity in the brain, primary and secondary responses, factors that influence the potentials, and clinical applications. The VEP section specifically addresses anatomy, physiology, waveform, methods of recording, abnormalities, and use in assessing visual pathway integrity. BAEP is described as assessing hearing in infants and localizing brainstem lesions. Sensory evoked potentials evaluate sensory pathway intactness while motor evoked potentials are recorded from muscles to diagnose neurological diseases.
Genetics Screening Of Human Cardiac Ryanodine Receptor Mutations In Ion ChannelTaruna Ikrar
1. The study analyzed 83 Japanese patients with various arrhythmic disorders including long-QT syndrome, Brugada syndrome, idiopathic ventricular fibrillation, arrhythmogenic right ventricular cardiomyopathy, and catecholaminergic polymorphic ventricular tachycardia (CPVT).
2. Genetic screening revealed 3 distinct mutations in the cardiac ryanodine receptor gene (RyR2) among 4 families with CPVT, representing a 75% incidence of RyR2 mutations in CPVT patients.
3. However, no RyR2 mutations were found in patients with long-QT syndrome, Brugada syndrome, idiopathic ventricular fibrillation, or arrhythmogenic right ventricular
This document summarizes a study on screening first-degree relatives of patients with bicuspid aortic valve. The study found a prevalence of bicuspid aortic valve of 5.9% in first-degree relatives screened, compared to 0.5-1% in the general population. Screening 184 first-degree relatives of 60 probands with bicuspid aortic valve identified 11 relatives with aortic valve abnormalities. The study concludes that echocardiographic screening of first-degree relatives is useful for identifying asymptomatic cases of bicuspid aortic valve.
This document summarizes the physiology and pharmacology of anticholinesterase drugs. It discusses the structure and function of nicotinic acetylcholine receptors and how conditions like trauma or disease can upregulate or downregulate these receptors. It describes how anticholinesterase drugs like neostigmina and edrophonium work by inhibiting acetylcholinesterase and preventing the breakdown of acetylcholine, allowing it to remain active in synaptic regions for longer. The document discusses variables like drug half-lives and clearance rates of various anticholinesterase medications. It also addresses factors that influence the antagonism of neuromuscular blocking drugs like the depth of block at time of administration and presence of inhal
ECoG involves placing electrodes directly on the surface of the exposed brain to record electrical activity with greater spatial resolution than traditional EEG. The document discusses using ECoG to monitor spreading depolarizations, waves of sustained neuronal depolarization that can propagate through brain tissue. Studies found spreading depolarizations commonly occur after traumatic brain injury and are associated with worse outcomes. ECoG may help guide individualized treatment by continuously monitoring these depolarizations in neuroICU patients.
The document discusses the history and development of implantable cardioverter defibrillators (ICDs) from their introduction in 1980 through dual chamber ICDs in 1997 and leadless ICDs in 2012. It then summarizes several major clinical trials that demonstrated the mortality benefits of ICD therapy in both primary and secondary prevention of sudden cardiac death. These trials showed reductions in overall mortality ranging from 20-55% and reductions in arrhythmic mortality ranging from 28-75% with ICD therapy.
This document discusses various techniques for monitoring patients in the intensive care unit (ICU), including electroencephalography (EEG), somatosensory evoked potentials (SSEPs), brain oxygen monitoring, intracranial pressure (ICP) monitoring, and cerebral blood flow monitoring using transcranial Doppler ultrasound. It provides examples of how these monitoring techniques can be used to detect seizures, brain injury, vasospasm, and other conditions in ICU patients.
Dr. sarah weckhuysen kcnq2 Cure summit parent track learn more at kcnq2cure.orgscottyandjim
This document discusses KCNQ2 gene mutations which can cause different epilepsy phenotypes from benign familial neonatal seizures (BFNS) to more severe early-onset epileptic encephalopathy. It describes the discovery of KCNQ2 mutations in BFNS in 1998 and more recent findings of de novo missense mutations in 10% of patients with treatment-resistant neonatal epileptic encephalopathy. These mutations have a dominant-negative effect on channel function and cause neuronal hyperexcitability. The document also reviews other ion channel mutations associated with epilepsy phenotypes along a spectrum, such as SCN1A mutations which can cause GEFS+ or more severe Dravet syndrome.
This document discusses using optic nerve sheath diameter (ONSD) measurements via ultrasound as a tool to assess increased intracranial pressure (ICP). It provides background on ONSD anatomy and evidence that ONSD changes mimic ICP changes. Studies show ONSD has high sensitivity and specificity for detecting elevated ICP compared to invasive monitoring. The document proposes a prospective study measuring ONSD in patients with conditions like end-stage liver disease, end-stage renal disease, and hypertensive crises to see if ONSD decreases after treatment and normalize, indicating reduced ICP. It suggests ONSD could help predict complications like dialysis disequilibrium syndrome.
1) Intraoperative neurophysiological monitoring utilizes evoked potentials and EEG to minimize morbidity from surgical manipulation and preserve nervous system function. Monitoring modalities assess nervous system blood flow, oxygenation, metabolism, and direct function.
2) Transcranial Doppler ultrasound, jugular venous oximetry, and near infrared spectroscopy noninvasively monitor cerebral blood flow and oxygenation. Microdialysis assesses cerebral metabolism by analyzing extracellular fluid.
3) Evoked potentials including somatosensory, motor, auditory, and visual evaluate specific neural pathways, while spontaneous EEG assesses global brain activity intraoperatively.
Advances in neuro anesthesia monitoringWesam Mousa
The document discusses various techniques for monitoring the brain during anesthesia to prevent neurological insults. It describes electroencephalography (EEG) techniques like raw EEG, bispectral index, and entropy which can detect cerebral ischemia. It also discusses evoked potentials like somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) using electrical stimulation to assess spinal cord and brain function. Additional monitoring methods covered are intracranial pressure (ICP), cerebral blood flow (CBF), brain oxygenation, and electromyography (EMG) for nerve function. The document emphasizes multimodal monitoring as the gold standard to reduce intraoperative neurological injury.
The document discusses evaluation and testing for syncope. It notes that history and physical exam are the best initial tools to determine etiology. Certain historical clues can suggest neurally-mediated, orthostatic, or seizure-related causes. Predictors of cardiac syncope include absence of pre-syncope, duration of loss of consciousness, and recovery pattern. Recommended tests include ECG, telemetry, Holter monitor, event recorder, and implantable loop recorder. ILR has a high diagnostic yield of 65-90% and may be useful when initial tests are non-diagnostic.
1) Status epilepticus refers to prolonged or continuous seizure activity lasting more than 5 minutes. It is a medical emergency that can cause neuronal damage the longer it persists.
2) Treatment involves controlling airway and vital signs, administering glucose and thiamine, performing diagnostic tests, and starting anticonvulsant drug therapy.
3) First line drug therapy includes lorazepam or diazepam followed by phenytoin or fosphenytoin. If seizures continue, additional doses of these drugs or alternative drugs like phenobarbital are given.
This document discusses status epilepticus (SE), including:
- Definitions and types of SE such as convulsive SE, nonconvulsive SE, and acute repetitive seizures.
- Characteristics of generalized convulsive SE.
- Incidence and mortality rates of SE which increase with age.
- Main causes of SE such as low antiepileptic drug levels, cerebrovascular accidents, anoxia/hypoxia, and metabolic disturbances.
- Guidelines for the management of SE including initiating treatment with benzodiazepines like lorazepam or diazepam, followed by antiepileptic drugs like fosphenytoin, phenytoin,
EEG measures the electrical activity of the brain through electrodes placed on the scalp. It can detect different wave patterns associated with different brain states. Evoked potentials involve stimulating a sensory pathway and measuring the electrical response along the pathway. This allows localization of lesions. Somatosensory evoked potentials involve stimulating a peripheral nerve like the median nerve and measuring the response along the pathway to detect spinal cord or brain injuries. Auditory evoked potentials involve measuring the brainstem response to a click stimulus to detect acoustic neuromas or other posterior fossa lesions. Both evoked potentials and EMG monitoring are used during surgery to detect injuries.
Post-traumatic epilepsy (PTE) is defined as recurrent seizures occurring after traumatic brain injury (TBI). TBI accounts for 10-20% of epilepsy cases. Risk factors for early PTE include GCS <10, intracranial hematoma, and seizures within 24 hours of injury. Risk factors for late PTE include penetrating injury, intracranial hematoma, early PTE, and age over 35. Temporal lobes are the most common localization. Standard anticonvulsants are used to treat established PTE but prophylaxis is ineffective at preventing late PTE. Surgery may be considered for refractory late PTE if the seizure focus is well-localized.
Evoked potentials are low amplitude electrical potentials recorded from the brain or peripheral nerves in response to sensory stimuli. They are used to evaluate the function of sensory and motor pathways. There are several types including sensory evoked potentials from visual, auditory and somatosensory stimulation as well as motor evoked potentials. Recording techniques involve signal averaging to detect the low amplitude signals. Evoked potentials provide objective measures for diagnosing various neurological disorders.
This document discusses epilepsy and anaesthesia. It provides definitions of seizures and epilepsy. It then discusses various factors that influence neuronal excitability like intrinsic factors related to ion channels and extrinsic factors like ion concentrations and synaptic remodeling. It explains the mechanisms of seizure initiation and propagation. It discusses the effects of various anaesthetic agents like inhalational agents, opioids, IV agents and local anaesthetics on seizures. It provides guidelines on perioperative management of anti-epileptic drugs. It also discusses status epilepticus, its treatment and refractory status epilepticus. The document concludes by covering various aspects of presurgical evaluation of epilepsy patients like neuroimaging, EEG, video-EEG, neuropsychological testing and WADA test
This document discusses pacemakers and their management during anesthesia. It begins by describing the components of the heart's conducting system and types of pacemakers. It then discusses indications for pacemakers and implantable cardioverter defibrillators. The key points regarding anesthetic management are to have the device interrogated preoperatively, monitor it closely intraoperatively, and avoid potential electromagnetic interference from devices like electrocautery or defibrillation. Regional anesthesia is usually safe but general anesthesia requires avoiding drugs that could interfere with pacemaker function.
Clinical imaging and molecular biomarkers of drug resistant epilepsy.pptxPramod Krishnan
Clinical, imaging and molecular biomarkers in drug resistant epilepsy
1. Several clinical factors predict drug resistant epilepsy including early age of onset, frequent seizures, neurological deficits, and failure to respond to initial treatment.
2. Imaging biomarkers such as abnormalities on MRI, focal hypometabolism on PET, and changes in diffusion can help identify potential epileptogenic lesions.
3. Molecular biomarkers reflect underlying pathological processes like abnormal excitatory/inhibitory neurotransmission, neuroinflammation, and changes in gene and protein expression that may contribute to drug resistance. Combining biomarkers provides a more precise approach to managing drug resistant epilepsy.
The document summarizes a study investigating clinical and electroencephalography (EEG) features of patients with nonconvulsive status epilepticus (NCSE). The study reviewed 45 patients over 5 years. The most common etiologies were acute symptomatic (58%) and cerebrovascular disease (49%). EEG patterns were classified using the Salzburg Consensus Criteria, with 25 definite, 30 possible, and 6 no NCSE. In-hospital mortality was high at 33%. Prognostic factors associated with mortality included potentially fatal etiology, refractory NCSE, use of anesthetics, multiple EEG patterns, and nonreactive EEGs. The criteria had high diagnostic accuracy but did not affect prognosis.
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.
The document summarizes a study of 13 patients with herpes simplex encephalitis. All patients underwent clinical exams, CSF analysis, and MRI or CT scans of the brain. CSF analysis showed lymphocytic pleocytosis and elevated proteins in all patients, and PCR testing detected HSV-1 DNA in the CSF of all patients. The most common radiological feature was involvement of the temporal lobes, seen bilaterally in many patients. Some patients also showed lesions in other brain regions. All patients received acyclovir treatment, with outcomes to be presented later in the document.
This document summarizes several landmark clinical trials that have impacted emergency medicine practice. It discusses trials regarding the use of tPA for acute ischemic stroke (NINDS, ECASS III), early goal-directed therapy for sepsis (Rivers, Surviving Sepsis), clinical decision rules for cervical spine imaging (NEXUS, Canadian C-Spine Rule), fluid resuscitation (SAFE Trial), use of steroids for Bell's Palsy (Sullivan et al, Berg et al), and CT sensitivity within 6 hours of headache onset for subarachnoid hemorrhage (Perry/Steill et al). Assessment scales for functional outcomes in various conditions are also outlined.
Presentation of Dr. Lluis Blanch at 8th Pulmonary Medicine Update Course, February 2008, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
O documento discute os procedimentos de ressuscitação cardiopulmonar (RCP) e desfibrilação precoce. Ele enfatiza a importância da RCP e desfibrilação rápidas para aumentar as taxas de sobrevivência após parada cardíaca, e descreve as etapas corretas do suporte básico e avançado de vida, incluindo abertura de vias aéreas, ventilação, massagem cardíaca, administração de drogas e desfibrilação.
Reposicao Volemica E Drogas Vasoativas Na UtiRodrigo Biondi
O documento discute o uso de reposição volêmica e drogas vasoativas na UTI. Ele descreve diferentes fluidos e volumes adequados para reposição volêmica e as razões para usar drogas vasoativas quando a ressuscitação inicial com volume não for eficaz. Em seguida, discute vários agentes vasoativos comuns usados na UTI, incluindo adrenalina, vasopressina, dopamina, terlipressina, dobutamina, levosimendan e noradrenalina.
O documento discute técnicas de sedação para terapia intensiva, incluindo objetivos como intubação orotraqueal e ventilação mecânica. Ele lista classes farmacológicas comuns como hipnóticos, benzodiazepínicos e opióides, além de vias de administração e monitorização. Também aborda situações especiais como intubação acordado e sequência rápida de intubação para evitar broncoaspiração.
O documento discute a sepse, incluindo suas definições, epidemiologia, fisiopatologia, casos clínicos e tratamento. A sepse afeta centenas de milhares de pessoas anualmente nos EUA e está associada a altas taxas de mortalidade e custos hospitalares significativos. O tratamento envolve identificar e tratar a infecção subjacente, estabilizar o paciente com fluidoterapia e vasopressores, e administrar antibióticos de amplo espectro de forma precoce.
O documento discute choque séptico e disfunção múltipla de órgãos. Apresenta definições de sepse, diagnóstico, fisiopatologia da resposta imune inata e disfunção de órgãos como o cardiovascular, respiratório, gastrointestinal, hepático, hematológico e renal durante a sepse. Também aborda avaliação clínica, exames, microbiologia e marcadores laboratoriais no paciente séptico.
A síndrome compartimental abdominal ocorre quando a pressão intra-abdominal aumenta acima de 20mmHg, causando disfunção de órgãos. Ela é comumente causada por ressuscitação volêmica após trauma ou cirurgia e pode levar a isquemia gastrointestinal, disfunção de múltiplos órgãos e acidose. O diagnóstico é clínico e por medição da pressão intra-abdominal, e o tratamento envolve medidas para reduzir a pressão através de suporte hemodinâmico, ventilatório, paracent
O documento discute técnicas avançadas de controle das vias aéreas, incluindo intubação traqueal, uso de máscaras laríngeas e combitube. Ele fornece detalhes sobre posicionamento correto, manobras para facilitar a visualização da laringe e dispositivos como bougies que podem auxiliar na intubação difícil. Erros comuns na intubação também são abordados, assim como técnicas para verificar a correta posição do tubo traqueal.
As principais causas da insuficiência hepática aguda incluem drogas, vírus, pós-ressecções hepáticas extensas e problemas vasculares. O tratamento envolve monitoramento da função hepática, terapia de suporte, infusão de N-acetilcisteína e possível transplante hepático caso a condição se agrave. A abordagem nutricional é essencial para manter a estabilidade metabólica do paciente.
1) A hemorragia digestiva pode ser alta ou baixa e tem diversas causas, sendo as úlceras pépticas e varizes de esôfago as principais;
2) O diagnóstico envolve exames como endoscopia, colonoscopia e cintilografia para localizar a origem do sangramento;
3) O tratamento depende da causa e gravidade e inclui ressuscitação, hemostasia endoscópica ou cirúrgica, e terapia medicamentosa com bloqueadores de bomba de prótons ou octreotide.
1) A embolia pulmonar é a obstrução de uma artéria pulmonar causada geralmente por um trombo que se desprende de veias nas pernas ou pélvis.
2) Os principais fatores de risco incluem imobilização, câncer, doenças cardíacas e coagulopatias.
3) Os sintomas mais comuns são desconforto torácico e dispneia, mas os sinais e sintomas podem variar desde um colapso circulatório até uma dor torácica leve.
O documento discute doenças neuromusculares, classificando-as em doenças dos nervos, da junção neuromuscular e dos músculos. Apresenta exemplos de doenças como atrofia muscular espinhal, esclerose lateral amiotrófica, polineuropatia aguda pós-infecciosa, miastenia gravis e neuromiopatia do doente crítico. Fornece detalhes sobre a classificação, etiologia, sintomas e tratamento destas condições.
DistúRbio HidroeletrolíTico E áCido BáSicoRodrigo Biondi
O documento discute distúrbios hidroeletrolíticos e ácido-básicos, incluindo como interpretar gasometrias para diagnosticar diferentes tipos de acidose e alcalose. Também aborda o tratamento de distúrbios como hiponatremia, hipernatremia e hiper/hipopotassemia.
O documento discute os estudos sobre o controle glicêmico estrito em terapia intensiva. Apesar de reduzir complicações em longo prazo, estudos recentes mostraram que metas glicêmicas muito baixas aumentam o risco de hipoglicemia, podendo ser prejudicial. Recomenda-se metas entre 140-180 mg/dl, com protocolos de insulina cuidadosos considerando fatores de risco para hipoglicemia.
O documento descreve as complicações hiperglicêmicas agudas da diabetes, cetoacidose diabética (CAD) e estado hiperglicêmico hiperosmolar (SHH). Detalha a fisiopatogenia, quadro clínico, diagnóstico, critérios de gravidade, avaliação laboratorial e tratamento com ênfase na hidratação, insulinoterapia e correção de distúrbios eletrolíticos e ácido-base.
O paciente foi admitido no CTI devido a endocardite bacteriana e insuficiência renal aguda. Apresenta infecção, disfunção cardíaca e renal, além de fatores de risco como tabagismo e doença cardiovascular pré-existente. Exames mostram derrame pleural, imagem suspeita de vegetação cardíaca e disfunção renal e hepática. Foi indicada cirurgia cardíaca e exames adicionais.
1. A monitorização hemodinâmica é importante para evitar disóxia tissular e falência orgânica precocemente identificando instabilidade hemodinâmica.
2. Sinais físicos como hipotensão, extremidades frias e alteração do nível de consciência são alertas importantes de instabilidade hemodinâmica.
3. Variáveis como débito cardíaco, lactato e saturação venosa de oxigênio podem ser medidas para avaliar a perfusão tissular de pacientes críticos.
Este documento discute o controle de infecções hospitalares na terapia intensiva, com foco no diagnóstico e prevenção da pneumonia associada à ventilação mecânica (VAP) e infecção da corrente sanguínea relacionada a cateter vascular (ICV-RC). Ele descreve as diretrizes para diagnóstico da VAP e ICV-RC, fatores de risco, medidas de prevenção como higienização das mãos e uso racional de antimicrobianos, e a importância da vigilância ativa para o cont
Suporte Enteral E Parenteral No Doente CríTicoRodrigo Biondi
[SUMMARY]
This clinical trial tests whether providing early parenteral nutrition (PN) in addition to enteral nutrition (EN) improves outcomes for critically ill patients compared to EN alone. Patients are randomly assigned to receive either EN only, with PN started if EN is insufficient after 7 days, or a combination of EN started on day 2 and PN started on day 3, with PN amount based on calories not provided by EN. The study aims to determine if early PN completion of EN leads to better patient outcomes.
1. INTENSIVE CARE UNIT / CONTINOUS EEG MONITORING
STAFFING AND IMPLEMENTATION
Maria Lucia Furtado de Mendonça
Iodete Carneiro do Prado
Elizabeth Maria D’Almeida Ribeiro
Ana Cláucida T. Mattos
3. CRITICAL CARE PATIENT:
Physiophatological changes are dynamic
Information must be dynamic
Neurophysiological abnormalities are detected
before clinical deterioration
Intervention before clinical deterioration
Therapeutic control
Early prognostic information
Differential diagnosis of conscience disturbances
6. POTENCIAL EVOCADO SÔMATO SENSITIVO:
Resistente a anestésicos e hipotermia
Correlação estabelecida com isquemia cerebral
Limitado a uma via neural
7. DOPPLER TRANSCRANIANO:
Detecta e quantifica sinais de microembolização (MES)
Detecta anormalidades hemodinâmicas intracranianas em tempo real
Não avalia função cerebral diretamente
8. INDICATIONS FOR ICU - CEEG :
Unexplained decrease in LOC
Detection of subclinical seizures
Unstable cerebral ischaemia
Early detection of vasospasm in SAH
Increased ICP with decrease in LOC
Prognosis
9. INDICATIONS FOR ICU - CEEG :
cont.
Uninformative bedside assessment:
Medication - induced coma with/
without NMB use
10. CEEG = “EKG MONITORING”
OF THE BRAIN
EKG EEG
1. SENSITIVE TO CARDIAC SENSITIVE TO CEREBRAL
ISCHEMIA ISCHEMIA
2. DETECTS CARDIAC ISCHEMIA DETECTS CEREBRAL ISCHEMIA
AT A REVERSIBLE STAGE AT A REVERSIBLE STAGE
3. CORRELATES WITH CARDIAC CORRELATES WITH CEREBRAL
BLOOD FLOW BLOOD FLOW
4. RAPIDLY AND ACCURATELY RAPIDLY AND ACCURATELY
DETECTS CARDIAC DETECTS EPILEPTIC ACTIVITY
ARRHYTHMIAS
Courtesy KG Jordan ,MD. 2006
11. Are nonconvulsive seizures a
significant problem in the ICU ??
YES!!!
35% of NeuroICU patients found to have seizures
(Jordan 1992)
22% of TBI patients have seizures, ½ of which are
nonconvulsive (Vespa 1999)
28% of ICH patients have seizures, ½ of which are
nonconvulsive (Vespa 2003)
15% of SAH patients have seizures (Claassen 2004)
44% of pediatric ICU patients have seizures on cEEG
(Jette, Hirsch 2006)
15. MOST CRITICAL CARE PATIENTS HAD EXCLUSIVELY
NONCONVULSIVE SEIZURES
WITHOUT CEEG, THE RECOGNITION OF NCSE
IS DELAYED OR MISSED
INCREASE RATES OF MORBIDITY AND MORTALITY
16. 74a
Passado de AVE
Sepse urinária
Insuficiência renal aguda
Uso de quinolona
Deterioração do nível de consciência
TORPOROSA ACORDOU APÓS 1 mg MIDAZOLAM
17. Quanto tempo um paciente agudo
necessita ficar monitorizado para
detecção de crises epilépticas ?
18. Tempo para gravar a primeira crise, comparando os pacientes comatosos
e não comatosos
48 horas ou mais podem ser necessários para detecção de crises epilépticas
não convulsivas em pacientes comatosos
Neurology 2004;62:1743-1748
20. “The singular focus in
neurocritical care is
to prevent or rapidly identify
and then reverse
brain ischemia
if it occurs”
21. CBF EEG CHANGE DEGREE OF
LEVEL NEURONAL INJURY
(ml/100gm/min)
35-70 NORMAL NO INJURY
25-35 EEG reveals a
LOSS OF FAST BETA
FREQUENCIES
USUALLY REVERSIBLE
“window of reversibility”
18-25 SLOWING OF BACKGROUND POTENTIALLY
T0 5-7HZ THETA REVERSIBLE
of
12-18 SLOWING TO 1-4HZ DELTA POTENTIALLY
ischaemic cerebral REVERSIBLE
< 8-10 injury
SUPRESSION OF ALL
FREQUENCIES
NEURONAL DEATH
Jordan K. JCN 2004
24. PADRÕES DE BOM PROGNÓSTICO
ELEMENTOS FISIOLÓGICOS DO SONO
REATIVIDADE
VARIABILIDADE
25. PADRÕES DE MAU PROGNÓSTICO
CRISES EPILÉPTICAS LENTO E NÃO REATIVO
MONÓTON O
26. PADRÕES DE MAU PROGNÓSTICO
SURTO SUPRESSÃO INATIVIDADE ELÉTRICA CEREBRAL
ESPEC. = 100%
LANCET 1998 , 352 : 1808-12
27. ML1
POTENCIAL EVODACO SÔMATO SENSITIVO CURTA LATÊNCIA – N. MEDIANO
APÓS 72 HORAS
NORMAL ANORMAL
COMPONENTE CORTICAL SEM COMPONENTE CORTICAL
28. Slide 27
ML1 Pacientes comatosos com CC bilat. tem o prognóstico incerto
Dra. Malu; 20/10/2003
29. ML2
POTENCIAL EVODACO SÔMATO SENSITIVO – N. MEDIANO - RCP
D 3 EM DIANTE
J Clin Neurophysiol 2000 17 (5) 486-97
Ted L. Rothstein
300
N= 572 251
2 50 229
200 ÓBITO OU EVP
15 0
144 RECUPERAÇÃO
10 0
50
0
0
PESS PESS
C/ CC S/ CC
PESS S/ CC BILATERAL APÓS PCR - SENS 68% VPP: 100%
30. Slide 28
ML2 META ANÁLISE DE COMA ANÓXICO ISQUÊMICO
E COMPONENTE COETICAL DA VIA SOMATO SENSITIVA EM 572 PACIENTES
Dra. Malu; 2/8/2003
31. SO...
DURING THE PAST 10 YEARS :
ICU/cEEG is becoming a
STANDART OF CARE
BUT...
Very few neurointensivists read EEG
There is a very shortage of EEGers to serve
this unmet patient need 24/7
33. CONTINUOUS EEG MONITORING IN ICU
NEUROPHYSIOLOGY TEAM
REAL TIME OBSERVATION “24/7”
ICU TEAM BASIC AND CONTINUOUS TRAINING
34. ICU/cEEG program
most successful with
collaboration of all who are
involved in the patient care
•Neurointensivist
•Intensivist
•Neurosurgeons
•Fellows/Residents
•ICU nurse
•Neurophysiologist
•Technologists
49. ICU team comfortable with waveform
recognition from their experience with
other monitors in the ICU.
They accept CEEG monitoring as natural
extension of physiologic monitoring to the
brain.
They embrace CEEG benefit to patient
care.
50. CONCLUSIONS:
EEG detects real time ischaemia and in reversible stages ;
Nonconvulsive seizures are common in critical care
patients, and is related to marked adverse effects;
ICU/cEEG is becoming a standart of care;
ICU patients need CEEG avaiable 24/7;
As well as basic and continuous training , remote observation
in real time by a specialist is possible;
Institutional support and comitment are funtamental points
to CEEG monitoring program success.
51. “ SOME PEOPLE DREAM OF SUCCESS...
WHILE OTHERS WAKE UP AND WORK HARD AT IT “