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.
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.
This presentation looks at abnormal EEG patterns with examples for each. Benign variants, artifacts and focal ictal patterns are not part of this presentation.
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.
This presentation looks at abnormal EEG patterns with examples for each. Benign variants, artifacts and focal ictal patterns are not part of this presentation.
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.
This presentation looks at EEG signal generation, pyramidal cells, recording of EEG, source localisation, polarity, analysis of dipole, derivations, montages,
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.
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.
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.
This presentation looks at EEG signal generation, pyramidal cells, recording of EEG, source localisation, polarity, analysis of dipole, derivations, montages,
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.
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.
This presentation describes the concept of temporal plus syndrome, pseudotemporal epilepsy and paradoxical temporal lobe epilepsy and how to differentiate them from temporal lobe epilepsy.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
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ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
2. Contents
• History
• nomenclature
• Definition of LPDs
• Classification
• Characteristics
• Evolution
• Etiology
• Pathophysiology
• Relation to seizures and prognosis
• Future direction
3. HISTORY
• Term “periodic” - Cobb & Hill in 1950 who described it
in 5 patients of encephalitis.
• first description of lateralized paroxystic activities -
Alajouanine et al (1955)
• PLEDS -“Chatrian et al” 1964
4. NOMENCLATURE
• Periodic (PDs) (La Roche, 2013)
– Repeating waveforms or discharges with relatively uniform morphology
occurring at nearly regular intervals.
– Applies only to single discharges lasting less than 0.5 second and not
bursts.
– Quantifiable interval between waveforms.
– Intervals have < 50% variation from cycle to cycle
• Generally varies less than 20% within an individual EEG but may vary
significantly from patient to patient; San Juan Orta (2009)
• Lateralized (L)
– unilateral hemispheric or focal patterns
– Can include PDs seen synchronously over both hemispheres but clearly
more prominent on one side
• Epileptiform ???......Controversy
– Hirsch et al (2013)- subcommittee of ACNS- replaced PLEDs with LPDs
(Lateralized Periodic Discharges)
10. 4 yr male, arrest with acute diffuse HIE with mild diffuse cerebral edema.
11.
12. 64 yr male, Lt hemisph infarction
EEG- Left hemisph dominant GPDs
13.
14.
15. Reiher et al. (1991) – observed brief and low amplitude focal stereotyped
rhythmic discharges (RDs) closely a/w higher amplitude interictal
epileptiform discharges; subdivided PLEDs as
• PLEDs proper (without RDs)
Class I - Aperiodic, throughout
Class II - Metronomic*, intermittent
Class III – Metronomic*, throughout
• PLEDs plus (with RDs)
Class IV - brief RDs < 1 sec
Class V - prolonged RDs
*Metronomic periodicity - recurrence of discharges at constant intervals
16. CHARACTERISTICS
Occurrence
• uncommon , incidence range of 0.1% - 1 %.
• Incidence increases when EEG is performed earlier in the disease course.
• commonly in older patient - stroke
• may also occur in children, infants- infections
Morphology
• Usually surface –ve bi-, tri- & polyphasic spikes and sharp waves,
• maximal ipsilateral to structural involvement
• amplitudes - 100 to 300 µV, may be higher
• Duration- between 100-300 msec
• Recurrence frequency – 1 per 0.5 to 4 sec (usually recur at least every 2 sec)
17. Features
• Persist during both REM and NREM sleep and sometimes recur
during drowsiness after disappearance in wakefulness.
• Reactivity to HV, photic and noxious stimuli is diminished or absent.
20. • PLEDs - a response to acute process.
• Stroke is most common cause.
• - Embolism >> thrombosis
- watershed infarcts >> single vessel stroke
- Post CEA hyperperfusion (Reigel et al. 1987)
• Acute cortical lesions with subcortical white matter involvement are
MC imaging finding in new-onset PLEDs
22. THEORIES OF PLEDs NEUROPHYSIOLOGY
• Pohlmann et al (1996) PLEDs are EEG signature of a dynamic
patho-physiological state in which unstable neurobiological processes
create an ictal-interictal continuum.
– an unstable brain state related to the combination of one or more of
seizures, structural injury and metabolic derangement
• No single common unifying mechanism
23. • Cobb and Hill (1950)
“Cortical isolation” hypothesis which suggested that PEDs could arise
from cortex that had been severed from subcortical structures usually
caused by a large white matter lesion.
• Lee 1988, Handforth 1994
PET and SPECT show hypermetabolism and hyperperfusion in PLED foci,
respectively but these reflect increased neuronal activity rather than seizure.
• Kalamangalam (2015)
synchronization of pre-existing local field potentials, through
enhancement of excitatory neurotransmission and inactivation of
inhibitory neurotransmission provoked by the PLED-associated disease
process
24. EVOLUTION OF PLEDS
• 90% acute PLEDs disappear within 4 weeks. (Schwartz 1973) or may evolve to
– Seizure
– Isolated high voltage slow waves with delta/theta activity
– Sporadic spikes or sharp waves
– May persist as Chronic PLEDs, some lasting 18 months to 20 years
(Westmoreland 1986)
– May be recurrent eg in TIAs and symptomatic epilepsy.
• With time PLED Plus evolve into periodic PLEDs (class 2 and 3) & then into
aperiodic PLEDs ( class 1).
– accompanied by decreased frequency of clinical seizures.
• Seizures higher in PLED Plus than PLEDs proper.
25.
26. PLEDs Mimics
• EKG artifact:
ECG artifact max in Temporal or occipital
PLEDs usually not as regular
• Other mimics:
External device artefact
Electrode artefact
27. PLEDs in HSE
•hallmark of HSE is pseudoperiodic slow complexes or PLEDs in the
setting of symptoms s/o CNS infection
•Seen in ~80% of adults at some point during illness
•Initially diffusely slow background is seen
within the first week periodic pattern manifests .
•characteristically unilateral, may be bilateral and independent
•temporal in predominance.
•recur per 1.0 to 2.5 sec and abate after weeks
•No correlation with mortality/ prognosis
28.
29.
30.
31.
32. PLEDs in CJD
•pseudoperiodic generalized sharp wave with diffuse slow background.
• biphasic or triphasic sharply contoured waveforms of varying durations
•repeat with a period of 0.5 to 2.0 sec and shorten with disease progress
•Rarely unilateral, typically anterior predominant
•appear within 3 months of onset in almost all
•frequently time locked to myoclonic jerks.
33.
34.
35.
36. Relation of PLEDs to seizures
• Seizures occur at a frequency of 58 – 100% in PLEDs
• Focal motor seizures are the commonest
• sometimes appear to be an interictal feature, may or may not presage
clinical or electrographic seizure
• seizures occur traditionally with PLEDs, but can exist in patients who
never develop either clinical or EEG Sz
• no significant association between seizures and etiology.
• No significant difference in degree of functional outcome between
patients with or without PLED-associated seizures
37. 38 patients (84.4%) of 45 with PLEDs experiencing a seizure disorder.
26 had their first seizure during their acute illness, as PLED was encountered.
8 had SE , and 7 had EPC
Sz can be- focal motor, sensorimotor, CPS, GTCS,, SE, EPC
38. • Schraeder et al, Epilepsia1980
20 of the 24 patients with PLEDs had seizures
Seizure disorders a/w PLEDs – may be more refractory
concurrent Sz and PLEDS = signif. mortality and morbidity
Pts with no seizures in a/w PLEDS have little chance of developing a
seizure disorder
.
39. • San juan Orta et al, Arch Neurol 2009
Prognosis depends on the underlying etiology
The worst prognosis noted for acute severe stroke
In patients with PLEDs, the absence of clinical seizures at the time of
detection were more associated with death,
those with non-neoplastic etiology - good clinical outcome ???? caveat
• Nei et al Epilepsia 1999
PLEDs are the only EEG feature related to poor outcome in SE
independent of etiology.
40. Controversy….Are PLEDs ictal?
? No
Interrupted by seizure and slowly return thereafter.
Are common and self limiting part of the EEG evolution of the acute lesions.
A transient postictal pattern in some epilepsy patients.
? Yes
Exceptionally in EPC, PLEDs may be time locked.
PET hypermetabolism and SPECT Hyperperfusuion reported
? Seizure ? Increased Neuronal metabolism
? A peri-ictal pattern
Sequential PLEDs.
Association with seizure vulnerability.
Focal hyperexcitability in penumbra zone
41. •Mortality was unchanged with or without treatment of patients with
PLEDs on cEEG
•PLEDs without structural lesion can be ictal, interictal or postictal
finding on EEG
resulted in a higher mortality rate.
42. 1. no standard management for diagnosis, prevention and Rx of
seizures associated to PLEDs
2. Strongly consider treatment if:
Presence of myoclonic or clonic movements, nystagmus or rhythmic
blinking time locked to appearance of PDs (ie, ictal PDs).
Decline in clinical state that coincides with onset of PD
History of any of the following:
epilepsy or recent clinical seizure/SE.
Acute structural lesion a/w high risk of seizures (SAH,ICH,TBI)
3. Start or maintain a conventional AED in all PLEDs without
escalating treatment unless clear ictal electrographic or clinical
semiology is observed
43. BIPLEDs
• defined as periodic discharges are independently and simultaneously
present in both hemispheres.
• First described in HSE
• far less common than PLEDs,
• Incidence in ICU: 4 to 22%, Routine EEG – 0.1%, as low as 0.09%
• Bilaterally asynchronous
• Differ in morphology, amplitude, repetition, rate, site of maximum
involvement
• higher risk for seizures, depressed consc., mortality than PLEDs
• greater vigilance for epileptic activity required than in PLEDs,
• approach to AED management is the same.
44. 46 yr male, acute infarct in bilateral occipital
lobes and posterior thalami
45.
46. 2 yr male, Post op, Arrest with CT s/o HIE
EEG- BiPLEDs
47.
48. PLEDS Vs BIPLEDS
• PLEDS
– Stroke – most common
– Focal seizures
– FND
– Coma
– Mortality less
– Imaging focal lesions
BiPLEDs
– Anoxia and CNS inf. MC,
– Generalized seizures
– FND - less
– Coma
– Mortality more
– Imaging B/L lesions
49. Ipsilateral Independent PLEDs (IpsiIPs)
• Rare subtype
• First described in 1996
• Ipsilateral but independent in temporal & topographical relationship
• Associated with
– Acute cerebral lesions
– Altered consciousness & seizures
– Resolution with time
50.
51. Multifocal PLEDS
• 3 or more independent foci of PLEDs located over both hemispheres.
• 3 foci are also called TriPLEDs.
• Reflect severe brain dysfunction
• significant mortality rate.
Lawn, Westmoreland & Sharbrough. Clin Neurophysiology 2000;111(12): 2125-2129
52.
53. PEDIMS
• Described by Frere et al – 1989
• Periodic epileptiform discharges in the mid line or “PEDIMS”
• Other than its location, this activity has same characteristics as
commonly encountered PLEDs.
• s/i association with underlying stroke and seizures
54. Chronic PLEDs
• Classified separately as they persist in serial recordings for several
weeks to months /years.
• Requires serial EEGs to document PLEDs.
• No definite differentiating characters in chronic vs. acute
• Background in between discharges usually normal
• Found in chronic cerebral lesions or long standing epilepsy.
old stroke, tuberous sclerosis, chronic abscess, porencephalic cyst.
55. SIRPID
Stimulus-induced rhythmic, periodic, or ictal discharges
•Periodic, rhythmic, or ictal-appearing discharges consistently induced by
alerting stimuli such as auditory stimuli, sternal rub, examination, suctioning,
turning, and other patient-care activities.
•s/i approximately 20% of cEEG monitoring
•fall somewhere along the ictal-interictal continuum.
•Clinical or subclinical/electrographic seizures in about half of the patients
•SE more frequently in focal or ictal appearing SIRPIDs
•treatment with a conventional AED,
•if already on AED, escalation not recommended
•After cardiac arrest, SIRPIDs a/w poor outcome
60. Future experimental studies
Should focus on role of cellular mechanisms underlying periodicity
Developing an organized approach to the management of common
EEG patterns encountered in ICU
61. References
1. Andraus ME, Andraus CF, Alves-Leon SV. Periodic EEG patterns: importance of their
recognition and clinical significance. Arquivos de neuro-psiquiatria. 2012 Feb;70(2):145-
51.
2. LaRoche S, editor. Handbook of ICU EEG monitoring. Demos Medical Publishing; 2012
Dec 20.
3. San juan Orta D, Chiappa KH, Quiroz AZ, Costello DJ, Cole AJ. Prognostic implications
of periodic epileptiform discharges. Archives of neurology. 2009 Aug 1;66(8):985-91.
4. Hirsch LJ, LaRoche SM, Gaspard N, Gerard E, Svoronos A, Herman ST, Mani R, Arif H,
Jette N, Minazad Y, Kerrigan JF. American Clinical Neurophysiology Society’s
standardized critical care EEG terminology: 2012 version. Journal of Clinical
Neurophysiology. 2013 Feb 1;30(1):1-27.
5. Reiher J, Rivest J, Maison FG, Leduc CP. Periodic lateralized epileptiform discharges
with transitional rhythmic discharges: association with seizures. Electroencephalography
and clinical neurophysiology. 1991 Jan 31;78(1):12-7.
6. Brenner RP, Schaul N. Periodic EEG patterns: classification, clinical correlation and
pathophysiology. J Clin Neurophysiol 1990;7:249-267.
62. 7. Abou Khalil B; Atlas of EEG and seizure semiology, Butterworth- Heinemann;
2005 Oct 15.
8. EEG patterns: classification, clinical correlation and pathophysiology. J Clin
Neurophysiol 1990;7:249-267.
9. García–Morales I, Garcia MT, Galán–Dávila L, Gómez–Escalonilla C, Saiz–Díaz
R, Martínez–Salio A, de la Peña P, Tejerina JA. Periodic lateralized epileptiform
discharges: etiology, clinical aspects, seizures, and evolution in 130 patients.
Journal of clinical neurophysiology. 2002 Mar 1;19(2):172-7.
10. Kalamangalam GP, Slater JD. Periodic lateralized epileptiform discharges and
afterdischarges: common dynamic mechanisms. Journal of clinical
neurophysiology: official publication of the American Electroencephalographic
Society. 2015 Aug;32(4):331.
11. Solaiman A, Memon A, Basha M, Avedian L. When Should We Treat Periodic
Lateralized Epileptiform Discharges (PLEDS)(P5. 061). Neurology. 2014 Apr
8;82(10 Supplement):P5-06
63. 12. de la Paz D, Brenner RP. Bilateral independent periodic lateralized epileptiform
discharges. Clinical significance. Arch Neurol 1981; 38: 713-715
13. Silbert PL, Radhakrishnan K, Sharbrough FW, Klass DW. Ipsilateral independent periodic
lateralized epileptiform discharges. Electroencephalography and clinical neurophysiology.
1996 Mar 31;98(3):223-6.
14. Lawn ND, Westmoreland BF, Sharbrough FW. Multifocal periodic lateralized
epileptiform discharges (PLEDs): EEG features and clinical correlations. Clinical
neurophysiology. 2000 Dec 31;111(12):2125-9.
15. Téllez-Zenteno JF, Pillai SN, Hill MD, Pillay N. Chronic PLEDs with transitional rhythmic
discharges (PLEDs-plus) in remote stroke. Epileptic disorders. 2007 May 24;9(2):164-9.
16. Lee JW. EEG in the ICU: what should one treat, what not?. Epileptologie. 2012;29:210-7.