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stop each seizure or neuromodulation of brain epilepsy system?
Brain Stimulation 8 (2015) 310e325
Contents lists available at ScienceDirect
Brain Stimulation journal homepage: www.brainstimjrnl.com
1ST INTERNATIONAL BRAIN STIMULATION CONFERENCE 2 A systematic review and meta-analysis of brief vs ultrabrief right unilateral electroconvulsive therapy for depression Dr Phern-Chern Tor MBBS, DFD(CAW), MMed(Psych) a, Dr Alison Bautovich MBBS b, Ms Min-Jung Wang MSC (Epidemiology) b, Dr Donel Martin MClinNeuro, PhD b, Dr Samuel B. Harvey MBBS, MRCGP, MRCPsych, FRANZCP, PhD b, Professor Colleen Loo MBBS, FRANZCP, MD b a Institute of Mental Health, Singapore b Black Dog Institute, University of New South Wales, Australia Introduction: Electroconvulsive therapy (ECT) is an effective depression treatment but with potential cognitive side effects. Ultrabrief pulse width (UBP) right unilateral (RUL) ECT is an increasingly used treatment option that can potentially combine efficacy with less cognitive side effects. However current trials are underpowered or have conflicting results. A systematic review and meta-analysis was conducted to evaluate the relative efficacy and cognitive effects of Brief Pulse (BP) and UBP RUL ECT. Methods: Databases were searched for all randomized, controlled and naturalistic prospective studies up till June 2013, comparing BP and UBP RUL ECT in depressed patients that reported formalized mood ratings for depression. Six studies met the inclusion criteria, comprising a total of 689 patients. Efficacy, cognitive, response and remission outcomes were extracted from each publication or obtained directly from its authors. Results: BP RUL ECT was significantly more efficacious (SMD: 0.25, CI: 0.08 e 0.41, p¼0.004), but showed significantly more cognitive side effects in all cognitive domains examined (global cognition, anterograde learning and recall, retrograde memory). The average number of treatment sessions given was 8.7 (BP ECT) and 9.6 (UBP ECT) (p¼<0.001). UBP had a lower remission rate (OR 0.71, CI: 0.51 e 0.99, p¼0.045), with a NNT of 13. Conclusions: BP compared with UBP RUL ECT was slightly more efficacious and required less treatment sessions, but greater cognitive side effects. Clinicians should consider UBP RUL ECT for patients not requiring an urgent response and at increased risk of cognitive side effects.
3 Deep Brain Stimulation In The Treatment OF Tardive Dyskinesia M. Puri , A. Albassam Bergen Regional Medical Center, USA Tardive dyskinesia is a severly disabling complication of typical antipsychotic treatment. Many treatment modalities have attempted to alleviate its symptoms with no clear benefit. There has been a growing body of literature in the last decade about significant improvement of TD symptoms in patients treated DBS of the GPi. The tolerability of the procedure and its relative safety might prove it to be a well recommended option
especially for refractory TD cases. We report a case a patient who suffered severe tardive dyskinesia which was resistant to change of medication, and the use of Cogentin, Benadryl or Botulinum toxin injections to alleviate her symptoms. She received DBS-GPi treatment which remarkably improved her symptoms. She has been followed up for the past two years with no complications.
4 Is the goal of brain stimulation for epilepsy just prevent/ stop each seizure or neuromodulation of brain epilepsy system? S. Chkhenkeli a,b, G. Magalashvili b, A. Otarashvili b, T. Rakviashvili b, G.S. Lortkipanidze b a The University of Chicago, Chicago, IL, U.S.A. b Tbilisi, Georgia Objective: Operative neuromodulation is the field of altering the activities of neurons or neural networks and produce therapeutic effects. Based on these principles, the aim of this study is to assess the efficacy of different methods of therapeutic deep brain stimulation (TDBS) for epilepsy depending on the site of stimulation and involved brain mechanisms, and to determine the ultimate goal of this method of treatment. Material and Methods: This study was performed in 150 patients (age range 21-40 y, illness duration 8-21 y). 54 patients received TDBS with implanted neurostimulators for 1-1.5 y (mean follow-up 1.2 y). In 96 patients, effects of TDBS were studied intraoperatively, or with temporary (2-8 w) implanted grids. Results: The study demonstrated that the interictal brain epileptic activity, focal epileptic discharges and spreading and generalized epileptic seizures developing in intractable epilepsy patients brain may be suppressed and terminated by direct stimulation of brain structures which possess an inhibitory function. Low (4-8 Hz) and high-frequency (50-130 Hz) TDBS suppresses and stops clinical seizure depending on the stimulated brain structure. TDBS of the brain inhibitory structures is considerably effective (87%) for the prevention and stop a clinical seizure than the cortical focus stimulation (20-27%). TDBS of brain inhibitory system resulted in the reduction of seizure frequency by 80-85% in 65 - 87% of patients, depending on the severity of illness, and revealed an outlasting suppressive effect on the epileptic activity suggesting a long-term modulation of the brain mechanisms. It is hypothesized that diffuse inhibitory system may be activated from different inputs and different neuromediatory systems can be engaged to suppress the brain epileptic activity. Conclusion: The neuromodulation for treatment of epilepsy requires increased efforts to turn it from incidental studies to a reliable beneficial therapeutic method. TDBS should be not directed to just predict or stop each particular seizure but we have to modulate brain intrinsic inhibitory mechanisms in order to increase their activity and pathogenetically cure the epilepsy patients.
Contents lists available at ScienceDirect
Brain Stimulation journal homepage: www.brainstimjrnl.com
1ST INTERNATIONAL BRAIN STIMULATION CONFERENCE 2 A systematic review and meta-analysis of brief vs ultrabrief right unilateral electroconvulsive therapy for depression Dr Phern-Chern Tor MBBS, DFD(CAW), MMed(Psych) a, Dr Alison Bautovich MBBS b, Ms Min-Jung Wang MSC (Epidemiology) b, Dr Donel Martin MClinNeuro, PhD b, Dr Samuel B. Harvey MBBS, MRCGP, MRCPsych, FRANZCP, PhD b, Professor Colleen Loo MBBS, FRANZCP, MD b a Institute of Mental Health, Singapore b Black Dog Institute, University of New South Wales, Australia Introduction: Electroconvulsive therapy (ECT) is an effective depression treatment but with potential cognitive side effects. Ultrabrief pulse width (UBP) right unilateral (RUL) ECT is an increasingly used treatment option that can potentially combine efficacy with less cognitive side effects. However current trials are underpowered or have conflicting results. A systematic review and meta-analysis was conducted to evaluate the relative efficacy and cognitive effects of Brief Pulse (BP) and UBP RUL ECT. Methods: Databases were searched for all randomized, controlled and naturalistic prospective studies up till June 2013, comparing BP and UBP RUL ECT in depressed patients that reported formalized mood ratings for depression. Six studies met the inclusion criteria, comprising a total of 689 patients. Efficacy, cognitive, response and remission outcomes were extracted from each publication or obtained directly from its authors. Results: BP RUL ECT was significantly more efficacious (SMD: 0.25, CI: 0.08 e 0.41, p¼0.004), but showed significantly more cognitive side effects in all cognitive domains examined (global cognition, anterograde learning and recall, retrograde memory). The average number of treatment sessions given was 8.7 (BP ECT) and 9.6 (UBP ECT) (p¼<0.001). UBP had a lower remission rate (OR 0.71, CI: 0.51 e 0.99, p¼0.045), with a NNT of 13. Conclusions: BP compared with UBP RUL ECT was slightly more efficacious and required less treatment sessions, but greater cognitive side effects. Clinicians should consider UBP RUL ECT for patients not requiring an urgent response and at increased risk of cognitive side effects.
3 Deep Brain Stimulation In The Treatment OF Tardive Dyskinesia M. Puri , A. Albassam Bergen Regional Medical Center, USA Tardive dyskinesia is a severly disabling complication of typical antipsychotic treatment. Many treatment modalities have attempted to alleviate its symptoms with no clear benefit. There has been a growing body of literature in the last decade about significant improvement of TD symptoms in patients treated DBS of the GPi. The tolerability of the procedure and its relative safety might prove it to be a well recommended option
especially for refractory TD cases. We report a case a patient who suffered severe tardive dyskinesia which was resistant to change of medication, and the use of Cogentin, Benadryl or Botulinum toxin injections to alleviate her symptoms. She received DBS-GPi treatment which remarkably improved her symptoms. She has been followed up for the past two years with no complications.
4 Is the goal of brain stimulation for epilepsy just prevent/ stop each seizure or neuromodulation of brain epilepsy system? S. Chkhenkeli a,b, G. Magalashvili b, A. Otarashvili b, T. Rakviashvili b, G.S. Lortkipanidze b a The University of Chicago, Chicago, IL, U.S.A. b Tbilisi, Georgia Objective: Operative neuromodulation is the field of altering the activities of neurons or neural networks and produce therapeutic effects. Based on these principles, the aim of this study is to assess the efficacy of different methods of therapeutic deep brain stimulation (TDBS) for epilepsy depending on the site of stimulation and involved brain mechanisms, and to determine the ultimate goal of this method of treatment. Material and Methods: This study was performed in 150 patients (age range 21-40 y, illness duration 8-21 y). 54 patients received TDBS with implanted neurostimulators for 1-1.5 y (mean follow-up 1.2 y). In 96 patients, effects of TDBS were studied intraoperatively, or with temporary (2-8 w) implanted grids. Results: The study demonstrated that the interictal brain epileptic activity, focal epileptic discharges and spreading and generalized epileptic seizures developing in intractable epilepsy patients brain may be suppressed and terminated by direct stimulation of brain structures which possess an inhibitory function. Low (4-8 Hz) and high-frequency (50-130 Hz) TDBS suppresses and stops clinical seizure depending on the stimulated brain structure. TDBS of the brain inhibitory structures is considerably effective (87%) for the prevention and stop a clinical seizure than the cortical focus stimulation (20-27%). TDBS of brain inhibitory system resulted in the reduction of seizure frequency by 80-85% in 65 - 87% of patients, depending on the severity of illness, and revealed an outlasting suppressive effect on the epileptic activity suggesting a long-term modulation of the brain mechanisms. It is hypothesized that diffuse inhibitory system may be activated from different inputs and different neuromediatory systems can be engaged to suppress the brain epileptic activity. Conclusion: The neuromodulation for treatment of epilepsy requires increased efforts to turn it from incidental studies to a reliable beneficial therapeutic method. TDBS should be not directed to just predict or stop each particular seizure but we have to modulate brain intrinsic inhibitory mechanisms in order to increase their activity and pathogenetically cure the epilepsy patients.