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MO37 Evaluation and prognosis of long latency somatosensory evoked potentials (N60) in coma
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Abstracts of the 13th European Congress of Clinical Neurophysiology / Clinical Neurophysiology 119 (2008), S1–S131
Result: Both patients (patient 1: mantle cell lymphoma, patient 2: common B ALL) developed acute GvHD 8 and 5 days after allogeneic HSCT and presented with acute, short-term-memory difficulties and confusion after 23 and 28 days. Both had mild hyponatremia. EEG showed PLEDs (periodic lateralized epileptiform discharges) in both patients, one progressed to a refractory non-convulsive status epilepticus. MRI displayed hyperintense signal in the hippocampal area, CSF-PCR was positive for HHV6. On autopsy, hippocampi showed massive neuronal loss and activated astrocytes compatible with HHV6-infection. In the literature EEG-features of 30 cases are reported: PLEDs in 5, diffuse or focal slowing in 21 and epileptic activity in 11 cases. MRI-, CSF- and autopsy findings were very similar to our patients. Conclusion: HHV6-encephalitis is a rare, potentially severe complication after HSCT. EEG is a helpful diagnostic tool. PLEDs are a prominent EEG-feature, often attributed to herpes-simplex-virus 1 (HSV1) encephalitis. Whereas HSV1 is susceptible to acyclovir, HHV6 only responds to foscarnet or gancyclovir. Therefore, it is important to consider HHV6-encephalitis in HSCT-patients showing PLEDs on EEG.
MO37 Evaluation and prognosis of long latency somatosensory evoked potentials (N60) in coma A. Raillon 2,3 , L. Mazzola 1,2 , P. Convers 1,2 , M. Coudrot 4 , J. Morel 4 , P. Giraux 3 , B. Laurent 1,2 1 INSERM EMI 879: Central Integration of Pain, Lyon, Saint Etienne, France; 2 Neurological Department, Bellevue Hospital, Saint Etienne, France; 3 Rehabilitation Department, Bellevue Hospital, Saint Etienne, France; 4 Intensive Care Department, Bellevue and Nord Hospital, Saint Etienne, France Purpose: The absence of N20 response after short latency somatosensory evoked potential (SEP) recording predicts a poor outcome in comatose patients. In this retrospective study, we tested long latency SEP (N60)’s contribution to prognosis in coma. Method: SEP (N20, N60) after median nerve stimulation and auditory evoked potential (BAEP and MLAEP) were recorded in 57 comatose patients combined with late latency auditory evoked potentials (LLAEP) (N100) in 43 of them. Coma was caused by trauma (n=14), anoxia (n=26) or other etiologies (n=18). Follow up was of three months after EP recording. Unawakeness was defined as a Glasgow score ≤ 11 included Glascow Outcome Scale ≤2 and Minimally Conscious States. We studied statistical correlation (Khi2) between N60 and patient’s outcome and between N60 and N100. Results: Whatever coma’s causes, N60 was present in 20(35%) patients and N20 was always normal in these cases. Twelve patients had neither N20 nor N60. None but one of them with traumatic coma awaked. Twenty-five patients had a N20 response without N60 response. Statistical analysis failed to observe any correlation between the poor outcome and the absence of N60 response. The negative predictive value of N60 and LLAEP was 0, 71 (0.56-0.86) and 0, 86 (0, 67-1, 04) respectively, LLAEP sensitivity (0.85) being better than N60 one (0, 42). Conclusion: In accordance with literature, N60 absence had a negative predictive value although there was no significant correlation between N60 potential’s absence and unfavourable outcome. N60 potential and LLAEP are correlated. N60 recording in association with the auditory potentials could give some more information about prognosis in comatose patients.
MO38 Clinical and neurophysiological prognosis of recovery of consciousness from post-traumatic vegetative state Marianna Cavinato 2 , Ulderico Freo 2 , Giampiero Giron 2 , Salvino Casson 1 , Paolo Tonin 1 , Konstantinos Koutsikos 1 , Francesco Piccione 1 , Antonio Merico 1 1 San Camillo Hospital, Venice, Italy; 2 Department of Anesthesiology, Padua University, Italy Purpose: Prognosis of recovery of consciousness is an important question for relatives and health professionals who treat patients suffering from posttraumatic vegetative state (VS). Therefore, the possible prediction of recovery of environmental interaction may have a considerable influence on decision about the level of care or services provided. Insofar, most studies have tested
different clinical and neurophysiological techniques as recovery predictors from acute brain damage. However, only a few investigations have assessed the prognostic value of brain potentials in VS. The objective of the present study was to evaluate predictive values of clinical and neurophysiological parameters of consciousness recovery from post-traumatic VS. Methods: 34 post traumatic VS patients were included in the study (19 men and 9 women, mean age 26±14). They were admitted to the Neurorehabilitation Department of S.Camillo Hospital after a mean of 50 days of stay in Intensive care units (ICUs) or Neurosurgical ICUs (NSICUs). BAEPs, SSEPs and ERPs were recorded at 2 months post-injury. The P3 component of ERPs was evoked in response to patient own name presented in a passive odd-ball paradigm. Clinical assessment was performed by the Disability Rating Scale (DRS) and the Level of Cognitive Function (LCF). Six months after the trauma, patients were classified as awake or still in VS. Results: Admission DRS scores correlate significantly with probability of recovery of consciousness (P<0.006). On admission, P3 was detected in 23 patients who all later recovered consciousness. A P3 could not be detected in 11 patients of whom 3 recovered within one year after trauma and 8 did not (P3 sensitivity 100%, specificity 89%). A logistic multivariate regression analysis showed that only the presence of a P3 was associated with a good probability of patient recovery. Conclusions: Although not absolute, P3 and DRS seem to display good prognostic values of consciousness recovery in post-traumatic VS.
W5 Autoimmune neuropathies Chairperson: E. Nobile-Orazio, Italy MO39 Acute combined central and peripheral nervous system demyelination in children Tanja Adamovic 1 , Emilie Riou 2 , Geneviève Bernard 2 , Michel Vanasse 1 , Jean-Claude Décarie 1 , Chantal Poulin 2 , France Gauvin 1 1 CHU Sainte-Justine, Université de Montréal. Montréal, Québec, Canada; 2 Montreal Children’s Hospital, Mc Gill University, Montréal, Québec, Canada Purpose: Reports of acute combined central nervous system (CNS) and peripheral nervous system (PNS) demyelination are rare in the paediatric literature. The current study aim to better define this entity by: 1) Assessing the importance of imaging and neurophysiological studies to establish diagnosis and determine prognosis of children with acute combined CNS and PNS demyelination. 2) Describing the incidence, clinical features and prognosis of a cohort of children with acute combined CNS and PNS demyelination; 3) Comparing these patients with children presenting with isolated acute CNS or PNS demyelination. Methods: A retrospective chart review of all children with CNS or PNS demyelination admitted between 1993 and 2006 in two tertiary care pediatric hospitals was undertaken. Results: Among 523 charts reviewed, 93 patients fulfilled criteria for either acute isolated CNS demyelination (n=37; 39.8%), acute isolated PNS demyelination (n=43; 46%) or acute combined CNS and PNS demyelination (n=13; 14%). There was a significant difference between the groups for age (median: 9.6 vs. 6.7 vs. 11.5; p=0.047), occurrence between 2000 and 2006 (48.6% vs. 44.2% vs. 84,6%; p=0.03), admission to the pediatric intensive care unit (8.1% vs. 30.2% vs. 58,3%; p=0.001), length of hospital stay (median: 8 days vs. 9 days vs. 29 days; p<0.001), use of steroids (51.5% vs. 7% vs. 75%; p<0.001) and immunoglobulins (10.8% vs. 81.4% vs. 75%; p<0.001) as well as occurrence of poor neurologic outcome at last follow-up (2.9% vs. 12.1%vs. 53.9; p=0.002). Conclusion: Acute combined CNS and PNS demyelination in children is not uncommon and carries a poorer outcome than isolated CNS or PNS demyelination. Systematic assessment of this entity is highly relevant. Further studies are necessary to better understand its risk factors, potential etiologies, optimal management and prognosis.
Abstracts of the 13th European Congress of Clinical Neurophysiology / Clinical Neurophysiology 119 (2008), S1–S131
Result: Both patients (patient 1: mantle cell lymphoma, patient 2: common B ALL) developed acute GvHD 8 and 5 days after allogeneic HSCT and presented with acute, short-term-memory difficulties and confusion after 23 and 28 days. Both had mild hyponatremia. EEG showed PLEDs (periodic lateralized epileptiform discharges) in both patients, one progressed to a refractory non-convulsive status epilepticus. MRI displayed hyperintense signal in the hippocampal area, CSF-PCR was positive for HHV6. On autopsy, hippocampi showed massive neuronal loss and activated astrocytes compatible with HHV6-infection. In the literature EEG-features of 30 cases are reported: PLEDs in 5, diffuse or focal slowing in 21 and epileptic activity in 11 cases. MRI-, CSF- and autopsy findings were very similar to our patients. Conclusion: HHV6-encephalitis is a rare, potentially severe complication after HSCT. EEG is a helpful diagnostic tool. PLEDs are a prominent EEG-feature, often attributed to herpes-simplex-virus 1 (HSV1) encephalitis. Whereas HSV1 is susceptible to acyclovir, HHV6 only responds to foscarnet or gancyclovir. Therefore, it is important to consider HHV6-encephalitis in HSCT-patients showing PLEDs on EEG.
MO37 Evaluation and prognosis of long latency somatosensory evoked potentials (N60) in coma A. Raillon 2,3 , L. Mazzola 1,2 , P. Convers 1,2 , M. Coudrot 4 , J. Morel 4 , P. Giraux 3 , B. Laurent 1,2 1 INSERM EMI 879: Central Integration of Pain, Lyon, Saint Etienne, France; 2 Neurological Department, Bellevue Hospital, Saint Etienne, France; 3 Rehabilitation Department, Bellevue Hospital, Saint Etienne, France; 4 Intensive Care Department, Bellevue and Nord Hospital, Saint Etienne, France Purpose: The absence of N20 response after short latency somatosensory evoked potential (SEP) recording predicts a poor outcome in comatose patients. In this retrospective study, we tested long latency SEP (N60)’s contribution to prognosis in coma. Method: SEP (N20, N60) after median nerve stimulation and auditory evoked potential (BAEP and MLAEP) were recorded in 57 comatose patients combined with late latency auditory evoked potentials (LLAEP) (N100) in 43 of them. Coma was caused by trauma (n=14), anoxia (n=26) or other etiologies (n=18). Follow up was of three months after EP recording. Unawakeness was defined as a Glasgow score ≤ 11 included Glascow Outcome Scale ≤2 and Minimally Conscious States. We studied statistical correlation (Khi2) between N60 and patient’s outcome and between N60 and N100. Results: Whatever coma’s causes, N60 was present in 20(35%) patients and N20 was always normal in these cases. Twelve patients had neither N20 nor N60. None but one of them with traumatic coma awaked. Twenty-five patients had a N20 response without N60 response. Statistical analysis failed to observe any correlation between the poor outcome and the absence of N60 response. The negative predictive value of N60 and LLAEP was 0, 71 (0.56-0.86) and 0, 86 (0, 67-1, 04) respectively, LLAEP sensitivity (0.85) being better than N60 one (0, 42). Conclusion: In accordance with literature, N60 absence had a negative predictive value although there was no significant correlation between N60 potential’s absence and unfavourable outcome. N60 potential and LLAEP are correlated. N60 recording in association with the auditory potentials could give some more information about prognosis in comatose patients.
MO38 Clinical and neurophysiological prognosis of recovery of consciousness from post-traumatic vegetative state Marianna Cavinato 2 , Ulderico Freo 2 , Giampiero Giron 2 , Salvino Casson 1 , Paolo Tonin 1 , Konstantinos Koutsikos 1 , Francesco Piccione 1 , Antonio Merico 1 1 San Camillo Hospital, Venice, Italy; 2 Department of Anesthesiology, Padua University, Italy Purpose: Prognosis of recovery of consciousness is an important question for relatives and health professionals who treat patients suffering from posttraumatic vegetative state (VS). Therefore, the possible prediction of recovery of environmental interaction may have a considerable influence on decision about the level of care or services provided. Insofar, most studies have tested
different clinical and neurophysiological techniques as recovery predictors from acute brain damage. However, only a few investigations have assessed the prognostic value of brain potentials in VS. The objective of the present study was to evaluate predictive values of clinical and neurophysiological parameters of consciousness recovery from post-traumatic VS. Methods: 34 post traumatic VS patients were included in the study (19 men and 9 women, mean age 26±14). They were admitted to the Neurorehabilitation Department of S.Camillo Hospital after a mean of 50 days of stay in Intensive care units (ICUs) or Neurosurgical ICUs (NSICUs). BAEPs, SSEPs and ERPs were recorded at 2 months post-injury. The P3 component of ERPs was evoked in response to patient own name presented in a passive odd-ball paradigm. Clinical assessment was performed by the Disability Rating Scale (DRS) and the Level of Cognitive Function (LCF). Six months after the trauma, patients were classified as awake or still in VS. Results: Admission DRS scores correlate significantly with probability of recovery of consciousness (P<0.006). On admission, P3 was detected in 23 patients who all later recovered consciousness. A P3 could not be detected in 11 patients of whom 3 recovered within one year after trauma and 8 did not (P3 sensitivity 100%, specificity 89%). A logistic multivariate regression analysis showed that only the presence of a P3 was associated with a good probability of patient recovery. Conclusions: Although not absolute, P3 and DRS seem to display good prognostic values of consciousness recovery in post-traumatic VS.
W5 Autoimmune neuropathies Chairperson: E. Nobile-Orazio, Italy MO39 Acute combined central and peripheral nervous system demyelination in children Tanja Adamovic 1 , Emilie Riou 2 , Geneviève Bernard 2 , Michel Vanasse 1 , Jean-Claude Décarie 1 , Chantal Poulin 2 , France Gauvin 1 1 CHU Sainte-Justine, Université de Montréal. Montréal, Québec, Canada; 2 Montreal Children’s Hospital, Mc Gill University, Montréal, Québec, Canada Purpose: Reports of acute combined central nervous system (CNS) and peripheral nervous system (PNS) demyelination are rare in the paediatric literature. The current study aim to better define this entity by: 1) Assessing the importance of imaging and neurophysiological studies to establish diagnosis and determine prognosis of children with acute combined CNS and PNS demyelination. 2) Describing the incidence, clinical features and prognosis of a cohort of children with acute combined CNS and PNS demyelination; 3) Comparing these patients with children presenting with isolated acute CNS or PNS demyelination. Methods: A retrospective chart review of all children with CNS or PNS demyelination admitted between 1993 and 2006 in two tertiary care pediatric hospitals was undertaken. Results: Among 523 charts reviewed, 93 patients fulfilled criteria for either acute isolated CNS demyelination (n=37; 39.8%), acute isolated PNS demyelination (n=43; 46%) or acute combined CNS and PNS demyelination (n=13; 14%). There was a significant difference between the groups for age (median: 9.6 vs. 6.7 vs. 11.5; p=0.047), occurrence between 2000 and 2006 (48.6% vs. 44.2% vs. 84,6%; p=0.03), admission to the pediatric intensive care unit (8.1% vs. 30.2% vs. 58,3%; p=0.001), length of hospital stay (median: 8 days vs. 9 days vs. 29 days; p<0.001), use of steroids (51.5% vs. 7% vs. 75%; p<0.001) and immunoglobulins (10.8% vs. 81.4% vs. 75%; p<0.001) as well as occurrence of poor neurologic outcome at last follow-up (2.9% vs. 12.1%vs. 53.9; p=0.002). Conclusion: Acute combined CNS and PNS demyelination in children is not uncommon and carries a poorer outcome than isolated CNS or PNS demyelination. Systematic assessment of this entity is highly relevant. Further studies are necessary to better understand its risk factors, potential etiologies, optimal management and prognosis.