- Email: [email protected]
36. CS11.2 deep brain stimulation in Parkinson disease
Abstracts / Clinical Neurophysiology 127 (2016) e304–e321
and how recordings should be acquired, reviewed and interpreted. These are meant to provide guidance for quality patient care services. doi:10.1016/j.clinph.2016.05.309
35. Continuous EEG implementation–interpretation—Aatif Husain (Medical Center and Neurodiagnostic Center, VA. Duke University, Durham, NC, USA) Patients admitted to the hospital with acute neurological problems have a high risk of having seizures. Since most of the seizures are nonconvulsive, continuous EEG (cEEG) monitoring is necessary to detect them. Up to 20% of critically ill patients undergoing cEEG monitoring are found to have seizures or status epilepticus. CEEG monitoring is being recognized as a necessary tool in the evaluation of neurologically critically ill patients. In this presentation, the implementation of a cEEG monitoring service will be discussed. Additionally, the proper selection of patients, duration of monitoring and the conditions for which cEEG monitoring is most useful will be discussed. doi:10.1016/j.clinph.2016.05.310
36. CS11.2 deep brain stimulation in Parkinson disease—Jay Shils (Neurophysiological Intraoperative Monitoring, Rush University Medical Center, Chicago, IL, USA) Surgical treatment for movement disorders in the basal ganglia dates back to the 1930’s when Meyers first described campotomy. In the 1940’s Spiegel and Wycis described the first human use of stereotactic surgery for treatment of psychiatric illnesses. From the 1930’s through the 1960’s neurophysiology played a small role in these procedures, but it was the work of Dr. Albe-Fessard in the 1960’s that opened the door for intra-operative micro-electrode recording that has become a critical tool for functional localization during movement disorders surgery and most centers. The neurophysiologists is no longer the reporter of previous events, the information gained, interpreted, and analyzed by the neurophysiologist is used by the surgeon to plan the course of the procedure. In order for the neurophysiologist to perform these actions they need to not only have a detailed knowledge of the anatomy, basic physiology, and equipment, they also need to be familiar. doi:10.1016/j.clinph.2016.05.311
37. Utility of trans-operatory localization of brain targets for neuromodulation in refractory epilepsy—Ana Luisa Velasco (Head of the Epilepsy Clinic, Neurology and Neurosurgery Service, General Hospital of Mexico, Mexico) Electrical neuromodulation to treat refractory seizures has been used as a functional alternative in patients in whom ablative surgery is not an option. When we talk about neuromodulation, several elements come into consideration. One of them is to select the stimulation target. In this matter, we consider there are two approaches: stop seizure propagation or generation. The decision is based on seizure type and etiology (using all diagnostic procedures in our hands to have a correct diagnosis). If we chose to stop propagation, a careful analysis of the neural paths that permit the epileptic activity to spread, has to be performed. Imaging studies and stereotactic technique are primordial to localize the area to be stimulated, but not enough. In these cases, the intraoperative monitoring plays a very
e311
relevant role. When anatomic and physiologic localization parameters are reached, the outcome of the patient improves dramatically. Intraoperative depth stimulation is performed using low frequency to obtain recruiting responses and high frequency to obtain DC shifts. Recording is performed in scalp EEG to localize responses. Deciding to halt seizure generation needs to precise, the epileptic focus intraoperative recording might not be the best strategy, and thus, intraoperative monitoring is limited. doi:10.1016/j.clinph.2016.05.312
38. Mapping eloquent cortical areas with direct electrical stimulation—Paul Shkurovich Bialik (Clinical Neurophysiology, Centro Medico ABC, Mexico City, Mexico) Neurosurgical treatment of lesions in close spatial proximity to eloquent areas of the brain remains a challenge. The knowledge of topographical anatomy is not always enough to determine resection extension of the lesion. To identify the anatomical relation of a lesion to a cortical area, and to define the maximum limits of such resection, several techniques are used to guide the procedure. Using such techniques, resection of lesions previously classified as unresectable became possible, with relative low morbidity. In order to maximize the extent of the resection, the available neurophysiological and non-neurophysiological tools include imaging studies, both structural and functional like intraoperative MRI. Critical functional areas of the brain like cognitive, motor and language function can be mapped preoperatively with functional MRI, diffusion tensor imaging fiber tracking, magnetoencephalography, and navigated transcranial magnetic stimulation, or intraoperatively by direct electrical stimulation of the cortex or subcortical white matter tracts. Cortical Stimulation Mapping using electrical stimulation is considered the gold standard for mapping functional regions of the brain to create a presurgical plan that maximizes the patient’s functional outcome. doi:10.1016/j.clinph.2016.05.313
39. Safety issues in the operating room—Jay Shils (Neurophysiological Intraoperative Monitoring, Rush University Medical Center, Chicago, IL, USA) Safety for the intra-operative monitoring team can be divided into three concerns: (A) the patient; (B) the operating room personnel; (C) the IOM and operating room equipment. Poor electronic isolation can potentially expose the patient to higher than normal currents in either the IOM electrodes touching the patient, or even other electrical conduits touching the patient such as from the cautery system. Simple impedance test only tell you whether or not an electrode is in contact with the patient, not whether or not it is in the correct place. Improper returns can cause erroneous data by picking up large signals that can obscure the real signals. The two biggest issues with the safety of the operating room personnel are the wires that go from the patient to the IOM equipment and the needles that many groups use for recording. A third, less common safety issue is the potential for electrode wires to be knocked about or even disconnected by the surgeon or assistants. All wires, whether going from the amp and stimulation boxes to the IOM machine, or electrode wires should be neatly hidden under the patient or OR table or run in a neat way, trying to follow areas that are hard to walk over. doi:10.1016/j.clinph.2016.05.314
and how recordings should be acquired, reviewed and interpreted. These are meant to provide guidance for quality patient care services. doi:10.1016/j.clinph.2016.05.309
35. Continuous EEG implementation–interpretation—Aatif Husain (Medical Center and Neurodiagnostic Center, VA. Duke University, Durham, NC, USA) Patients admitted to the hospital with acute neurological problems have a high risk of having seizures. Since most of the seizures are nonconvulsive, continuous EEG (cEEG) monitoring is necessary to detect them. Up to 20% of critically ill patients undergoing cEEG monitoring are found to have seizures or status epilepticus. CEEG monitoring is being recognized as a necessary tool in the evaluation of neurologically critically ill patients. In this presentation, the implementation of a cEEG monitoring service will be discussed. Additionally, the proper selection of patients, duration of monitoring and the conditions for which cEEG monitoring is most useful will be discussed. doi:10.1016/j.clinph.2016.05.310
36. CS11.2 deep brain stimulation in Parkinson disease—Jay Shils (Neurophysiological Intraoperative Monitoring, Rush University Medical Center, Chicago, IL, USA) Surgical treatment for movement disorders in the basal ganglia dates back to the 1930’s when Meyers first described campotomy. In the 1940’s Spiegel and Wycis described the first human use of stereotactic surgery for treatment of psychiatric illnesses. From the 1930’s through the 1960’s neurophysiology played a small role in these procedures, but it was the work of Dr. Albe-Fessard in the 1960’s that opened the door for intra-operative micro-electrode recording that has become a critical tool for functional localization during movement disorders surgery and most centers. The neurophysiologists is no longer the reporter of previous events, the information gained, interpreted, and analyzed by the neurophysiologist is used by the surgeon to plan the course of the procedure. In order for the neurophysiologist to perform these actions they need to not only have a detailed knowledge of the anatomy, basic physiology, and equipment, they also need to be familiar. doi:10.1016/j.clinph.2016.05.311
37. Utility of trans-operatory localization of brain targets for neuromodulation in refractory epilepsy—Ana Luisa Velasco (Head of the Epilepsy Clinic, Neurology and Neurosurgery Service, General Hospital of Mexico, Mexico) Electrical neuromodulation to treat refractory seizures has been used as a functional alternative in patients in whom ablative surgery is not an option. When we talk about neuromodulation, several elements come into consideration. One of them is to select the stimulation target. In this matter, we consider there are two approaches: stop seizure propagation or generation. The decision is based on seizure type and etiology (using all diagnostic procedures in our hands to have a correct diagnosis). If we chose to stop propagation, a careful analysis of the neural paths that permit the epileptic activity to spread, has to be performed. Imaging studies and stereotactic technique are primordial to localize the area to be stimulated, but not enough. In these cases, the intraoperative monitoring plays a very
e311
relevant role. When anatomic and physiologic localization parameters are reached, the outcome of the patient improves dramatically. Intraoperative depth stimulation is performed using low frequency to obtain recruiting responses and high frequency to obtain DC shifts. Recording is performed in scalp EEG to localize responses. Deciding to halt seizure generation needs to precise, the epileptic focus intraoperative recording might not be the best strategy, and thus, intraoperative monitoring is limited. doi:10.1016/j.clinph.2016.05.312
38. Mapping eloquent cortical areas with direct electrical stimulation—Paul Shkurovich Bialik (Clinical Neurophysiology, Centro Medico ABC, Mexico City, Mexico) Neurosurgical treatment of lesions in close spatial proximity to eloquent areas of the brain remains a challenge. The knowledge of topographical anatomy is not always enough to determine resection extension of the lesion. To identify the anatomical relation of a lesion to a cortical area, and to define the maximum limits of such resection, several techniques are used to guide the procedure. Using such techniques, resection of lesions previously classified as unresectable became possible, with relative low morbidity. In order to maximize the extent of the resection, the available neurophysiological and non-neurophysiological tools include imaging studies, both structural and functional like intraoperative MRI. Critical functional areas of the brain like cognitive, motor and language function can be mapped preoperatively with functional MRI, diffusion tensor imaging fiber tracking, magnetoencephalography, and navigated transcranial magnetic stimulation, or intraoperatively by direct electrical stimulation of the cortex or subcortical white matter tracts. Cortical Stimulation Mapping using electrical stimulation is considered the gold standard for mapping functional regions of the brain to create a presurgical plan that maximizes the patient’s functional outcome. doi:10.1016/j.clinph.2016.05.313
39. Safety issues in the operating room—Jay Shils (Neurophysiological Intraoperative Monitoring, Rush University Medical Center, Chicago, IL, USA) Safety for the intra-operative monitoring team can be divided into three concerns: (A) the patient; (B) the operating room personnel; (C) the IOM and operating room equipment. Poor electronic isolation can potentially expose the patient to higher than normal currents in either the IOM electrodes touching the patient, or even other electrical conduits touching the patient such as from the cautery system. Simple impedance test only tell you whether or not an electrode is in contact with the patient, not whether or not it is in the correct place. Improper returns can cause erroneous data by picking up large signals that can obscure the real signals. The two biggest issues with the safety of the operating room personnel are the wires that go from the patient to the IOM equipment and the needles that many groups use for recording. A third, less common safety issue is the potential for electrode wires to be knocked about or even disconnected by the surgeon or assistants. All wires, whether going from the amp and stimulation boxes to the IOM machine, or electrode wires should be neatly hidden under the patient or OR table or run in a neat way, trying to follow areas that are hard to walk over. doi:10.1016/j.clinph.2016.05.314