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P263 Effect of structural complexities in head modelling on neonatal EEG source analysis
e262
Abstracts / Clinical Neurophysiology 128 (2017) e178–e303
Objectives: To describe a spindle-shaped ripple observed in normal scalp EEG of children and to describe its correlation with age. Methods: We included 22 patients from age 1 to 14 years. All children had a wake and sleep EEG without spikes. We marked ripples in sleep EEG, filtered between 80 and 250 Hz, in bipolar montage. We determined mean frequency, duration and root mean square amplitude. We counted the number of events per channel and calculated ripple rate over a period of 10 min. We categorised patients according to three groups: (1) no neurological diagnosis; (2) no epilepsy, but brain disorder; (3) diagnosis of epilepsy. In the ten children without a neurological diagnosis, we ran a lineal regression model with 10log transformed cumulative ripple rate as dependent variable and age as predictor. Results: We found this spindle-shaped ripple in 19 out of 22 children across diagnostic groups. Ripples occurred mostly on central channels (Cz-Pz). Mean frequency was 102 Hz, mean duration 70 ms, mean root mean square amplitude 0.95 lV. Ripple rate was negatively correlated with age (F(1, 8) = 6.74; p = 0.03). Discussion: The occurrence of these spindle-shaped ripples in normal EEGs and in healthy children indicates that this ripple activity is physiological. The negative correlation with age suggests its occurrence might be related to brain development. Conclusions: Scalp EEGs without spikes can reveal physiological ripples in children. Significance: This is the first study to describe physiological high frequency oscillations recorded in human neocortex with scalp EEG. Keywords: High frequency oscillations, surface EEG doi:10.1016/j.clinph.2017.07.268
P261 Cortical excitability changes in the earliest stages of amyotrophic lateral sclerosis (ALS)—Sophia Volik 1, Sergey Nikitin 2, Eugenia Naumova 2 (1 Moscow Medical Rehabilitation Center, Clinical Neurophysiology, Moscow, Russia, 2 Medical Center ‘‘Practical Neurology”, Society of Experts in Neuromuscular Disease, Clinical Neurophysiology, Moscow, Russia) Objectives: To reveal CE changes in the earliest stages of ALS. Methods: The prospective analysis of CE tested with TMS was done with 11 patients at the earliest stage of ALS when the diagnosis was considered as ‘‘possible ALS” according to the Awaji and El Escorial criteria. The ‘‘possible ALS” was established in 3 patients with signs of frontotemporal dementia and 4 patients had bulbar onset. In all patients, the resting motor threshold (RMT) was checked with the motor evoked potential (MEP) recorded bilateral from abductor pollicis brevis (ABP) and tibialis anterior (TA) muscles. There was no subjective weakness in target muscles but the normal or increased tendon reflexes. After 1.8–2.2 years of the follow up period, the diagnosis of ALS corresponded all the criteria of reliable disease with upper and lower motor neuron involvement. Results: In the early stages of possible ALS the RMT registered from the upper and lower extremities was normal: APB 40 ± 5%, TA 65 ± 7%. The paradoxical ‘‘normality” did not correlate to clinical features provided evidence of upper motor neuron involvement.The MEP amplitude was normal. After 1.8–2.2 years, in all cases, the RMT increased or MEP was absent. Conclusions: In the earliest stages of ALS the level of RMT doesn’t differ from measurements in normal individuals, and can’t be used as the parameter of suggesting CE changes. Significance: The question of what one mean by early stages of ALS is the most vulnerable issue in investigations of CE in motor neuron disease.
Keywords: Amyotrophic lateral sclerosis, Cortical excitability, Resting motor threshold, Early stages doi:10.1016/j.clinph.2017.07.269
P262 Contraceptive implant induced ulnar neuropathy—J. Kilby, W.L. Merton, A.N. Pandya (School of Pharmacy and Biological Sciences, University of Portsmouth, Queen Alexandra Hospital, Portsmouth, United Kingdom) Significant complications from subdermal insertion of a contraceptive implant in the medial upper arm are rare; a UK Government drug safety update indicating the risk of intravascular insertion was published in 2016.We report the introduction of an implant into the ulnar nerve sheath. Introduction of a contraceptive implant into the medial aspect of the distal left upper arm was followed 5 min later by the patient reporting pins and needles in the arm and tips of the left ring and little fingers. The implant was not palpable. 2 h later loss of sensation was apparent in these fingers; clinical review was unrevealing. Ultrasound suggested the implant was lying between the ulnar nerve and blood vessel in the medial upper arm. At surgery the implant was found within the left ulnar nerve sheath and removed.3 months post surgery the numbness in the little finger had resolved but reduced sensation was still evident over the dorsoulnar hand and distal forearm with hypersensitivity over the ulnar styloid, weakness was not apparent. Nerve conduction studies revealed the left dorsal ulnar sensory NAP was small when compared to the right side (13 vs. 31 microvolts).The left digit 5 sensory NAP was normal amplitude. Motor studies showed mild slowing in the left ulnar nerve around the elbow. While publications and warnings have highlighted the rare occurrence of intravascular insertion, the neurovascular bundle is at risk hence drug company advice to avoid the sulcus between biceps and triceps. This case indicates fascicular damage to the ulnar nerve.
Keywords: Contraceptive implant, Ulnar neuropathy doi:10.1016/j.clinph.2017.07.270
P263 Effect of structural complexities in head modelling on neonatal EEG source analysis—Hamed Azizollahi, Ardalan Aarabi, Fabrice Wallios (INSERM U1105, GRAMFC, Université de Picardie Jules Verne, CHU SUD, Amiens, France) Objective: The accuracy of electroencephalography source reconstruction largely depends on the accuracy of head model, which, in turn, is dependent on the geometry and electrical properties of head tissues. Methods: Based on a MR/CT coregistered images of one neonate we created a highly realistic 6 compartment head model. using a state of art finite element method, we performed numerical simulations to investigate localization errors in dipole source position, orientation and magnitude caused by CSF and fontanel exclusion and GM/WM distinction. Results: Our results showed that exclusion of CSF from the head model caused source localization errors up to 7.5 mm. GM/WM distinction affected widely all sources with localization errors up to 4.3 mm. Exclusion of the fontanels led to localization errors of less
Abstracts / Clinical Neurophysiology 128 (2017) e178–e303
than 4.9 mm specifically for sources located in the areas beneath the fontanels. The majority of sources showed orientation errors up to 24.6°, 19.2° and 17.6°, caused by CSF exclusion, GM/WM distinction and fontanel exclusion, respectively. Discussion: Our results systematically emphasized the importance of the inclusion of the CSF as a highly conductive layer and GM/WM distinction in head model construction. The exclusion of fontanels also led to substantial local localization errors for sources located in the areas beneath the fontanels. Conclusion: In this study we investigated the effect of different head compartments in neonatal head models on EEG source analysis. Significance: Our findings have practical implications for a better understanding of the importance of inaccuracies in head model and their impact on localization of brain electrical activity in neonates. Keywords: EEG, Source localization, CSF, Gray mater, White mater, Head model, Fontanels, Finite element method, Neonates doi:10.1016/j.clinph.2017.07.271
P264 Sjögren’s syndrome presenting with myelitis and without SICCA symptoms—Hacer Erdem Tilki, Sß eyda Bayil (Ondokuz Mayıs University, Department of Neurology, Samsun, Turkey) Sjögren’s syndrome (SS) is a chronic inflammatory disorder of exocrine glands with autoimmune etiology. Sjögren’s syndrome affect the nervous system in approximately 20% of cases. The prevalence of peripheral and central neurological manifestations in Sjögren syndrome are about 15% and 5% respectively. Neurological symptoms may occur before the onset of SICCA symptoms (dry eyes and dry mouth). Anti-Ro/SSA and anti-La/SSB antibodies are present 50–70% of patients with Sjögren syndrome. Patients with SS that have neurological symptoms, only 21% have anti-SSA or anti-SSB antibodies. In this article, we report a patient with SS, presenting as myelitis without any SICCA symptoms and without any Anti-Ro/ SSA and anti-La/SSB antibodies in the sera of patient. Most common peripheral nervous system (PNS) presentations are axonal polyneuropathies (distal axonal sensory and sensorimotor), sensory ganglionopathy, motor neuropathy, small fiber neuropathy, multiple mononeuritis, trigeminal and other cranial neuropathies, autonomic neuropathies, demyelinating polyradiculoneuropathy. The sensory neuropathies constitute the most frequent PNS complication. Central nervous system (CNS) manifestations of Sjögren’s syndrome may affect spinal cord, brain stem, optic nerves, cerebellum, and cerebral hemispheres. CNS involvement is much less common than peripheral nervous system involvement. Transverse myelitis is an inflammatory disorder of the spinal cord that presents acutely. The presence of sensorial axonal polyneuropathy and longitudinally extensive transverse myelitis that spans the servical and thoracic spinal cord led us thinking about SS. The positive Schirmer’ test and lip biopsy supported the diagnosis of SS. So, it is important to consider SS in differential diagnosis even if there is no SICCA syndrome or even if autoantibodies are negative. Keyword: Sjögren syndrome SICCA doi:10.1016/j.clinph.2017.07.272
P265 Correlation of thyroid function disturbances and amyotrophic lateral sclerosis syndrome—Tinatin Kherkheulidze 1, Maia Beridze 2, Nana Kvirkvelaia 3, Omar Samushia 3, Tsira
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Manjgaladze 2, Nino Khizanishvhili 4, Eka Devidze 2 (1 Tbilisi State Medical University, HTMC Clinic, Neurology/Neurosurgery Department, Tbilisi, GA, United States, 2 Tbilisi State Medical University, First University Clinic, Neurology Department, Tbilisi, GA, United States, 3 Tbilisi State Medical University, Neurology Department, Tbilisi, GA, United States, 4 Petre Sarjishvili Institute of Neurology, Neurology/Neurophysiology Department, Tbilisi, GA, United States) Background: Coexistence of Amyotrophic Lateral Sclerosis Syndrome (ALS-S) with thyroid disturbances is long ago noticed. Though, previous research did not confirm the role of thyroid hormones in ALS-S. Purpose: to research the role of thyroid gland hormones and free radicals in patients with ALS-S. Methods: Totally 52 patients aged 51–67 years with ALS-S investigated neurologically from endemic goiter area of Georgia. ALS was proved by Neuro-MEP-Micro (version 2009) 2-channel portable EMG. Serum levels of thyroxine (FT4), thyroid stimulating hormone (TSH) and antibodies against thyroid peroxidase (anti-TPO) were detected. The hormone levels analyzed by an electrochemiluminescence method on the apparatus Roche E411. Blood free radicals detected by Electron Paramagnetic Resonance Method (EPR). Statistics performed by SPSS-11.0. Results: Neurologically was found spastic-atrophic changes of the limb muscles in each patient. EMG showed signs of motor neurons’ damage. From all ALS-S patients 38 (73%) found to have hypothyroidism (TSH = 14 ± 2.4 mIU/L, FT4 = 1.7 ± 0.8 ug/dL, antiTPO = 35 ± 5.5 IU/ml); 14 patients (27%) diagnosed as Hashimoto’s thyroiditis (TSH = 11 ± 2.6 mIU/L, FT4 = 2.6 ± 0.7 ug/dL, antiTPO = 300 ± 45.5 IU/ml). Blood lypoperoxiradical (LOO-) was detected in all ALS-S patients. Positive correlation was found between the blood data of anti-TPO and blood data of LOO-. All patients were given appropriate treatment for thyroid disturbances. After 6 months treatment patients’ health was clinically improved, increased volume of innervation by EMG. Conclusion: According to the present study autoimmunity definitely assists to the promotion of free radical pathology in ALS-S and investigations in this direction should be continued. Keywords: EMG, Amyotrophic lateral sclerosis, Thyroid function disturbances, Free radicals doi:10.1016/j.clinph.2017.07.273
P266 Periodics lateralized épileptiform discharges recorded in a centro-pontic myelinolysis, A case report—Fatima Zohra Benchohra (Medecine Faculty of Mostaganem, Physiology Laboratory, Mostaganem, Algeria) Objectives: For some authors, the PLEDs are the EEG expression of a dynamic physiopathological state in which an unstable neurobiological process creates a critical-intercritical continum in relation to the nature of the underlying neuro-neuronal damage, Preexisting ability of the patient to develop epileptic seizures and the coexistence of metabolic disorder [1,2]. We report the case of a young patient with centro-pontic myelinolysis in whom PLEDS were recorded. Materials and methods: Observation: a 25-year-old patient with no medical history, hospitalized in the internal medicine department for management of acute renal failure (ARI), cytolysis, severe hyponatremia, over 18 weeks pregnancy Of amenorrhea, poisoning with thistle algae was strongly suspected.
Abstracts / Clinical Neurophysiology 128 (2017) e178–e303
Objectives: To describe a spindle-shaped ripple observed in normal scalp EEG of children and to describe its correlation with age. Methods: We included 22 patients from age 1 to 14 years. All children had a wake and sleep EEG without spikes. We marked ripples in sleep EEG, filtered between 80 and 250 Hz, in bipolar montage. We determined mean frequency, duration and root mean square amplitude. We counted the number of events per channel and calculated ripple rate over a period of 10 min. We categorised patients according to three groups: (1) no neurological diagnosis; (2) no epilepsy, but brain disorder; (3) diagnosis of epilepsy. In the ten children without a neurological diagnosis, we ran a lineal regression model with 10log transformed cumulative ripple rate as dependent variable and age as predictor. Results: We found this spindle-shaped ripple in 19 out of 22 children across diagnostic groups. Ripples occurred mostly on central channels (Cz-Pz). Mean frequency was 102 Hz, mean duration 70 ms, mean root mean square amplitude 0.95 lV. Ripple rate was negatively correlated with age (F(1, 8) = 6.74; p = 0.03). Discussion: The occurrence of these spindle-shaped ripples in normal EEGs and in healthy children indicates that this ripple activity is physiological. The negative correlation with age suggests its occurrence might be related to brain development. Conclusions: Scalp EEGs without spikes can reveal physiological ripples in children. Significance: This is the first study to describe physiological high frequency oscillations recorded in human neocortex with scalp EEG. Keywords: High frequency oscillations, surface EEG doi:10.1016/j.clinph.2017.07.268
P261 Cortical excitability changes in the earliest stages of amyotrophic lateral sclerosis (ALS)—Sophia Volik 1, Sergey Nikitin 2, Eugenia Naumova 2 (1 Moscow Medical Rehabilitation Center, Clinical Neurophysiology, Moscow, Russia, 2 Medical Center ‘‘Practical Neurology”, Society of Experts in Neuromuscular Disease, Clinical Neurophysiology, Moscow, Russia) Objectives: To reveal CE changes in the earliest stages of ALS. Methods: The prospective analysis of CE tested with TMS was done with 11 patients at the earliest stage of ALS when the diagnosis was considered as ‘‘possible ALS” according to the Awaji and El Escorial criteria. The ‘‘possible ALS” was established in 3 patients with signs of frontotemporal dementia and 4 patients had bulbar onset. In all patients, the resting motor threshold (RMT) was checked with the motor evoked potential (MEP) recorded bilateral from abductor pollicis brevis (ABP) and tibialis anterior (TA) muscles. There was no subjective weakness in target muscles but the normal or increased tendon reflexes. After 1.8–2.2 years of the follow up period, the diagnosis of ALS corresponded all the criteria of reliable disease with upper and lower motor neuron involvement. Results: In the early stages of possible ALS the RMT registered from the upper and lower extremities was normal: APB 40 ± 5%, TA 65 ± 7%. The paradoxical ‘‘normality” did not correlate to clinical features provided evidence of upper motor neuron involvement.The MEP amplitude was normal. After 1.8–2.2 years, in all cases, the RMT increased or MEP was absent. Conclusions: In the earliest stages of ALS the level of RMT doesn’t differ from measurements in normal individuals, and can’t be used as the parameter of suggesting CE changes. Significance: The question of what one mean by early stages of ALS is the most vulnerable issue in investigations of CE in motor neuron disease.
Keywords: Amyotrophic lateral sclerosis, Cortical excitability, Resting motor threshold, Early stages doi:10.1016/j.clinph.2017.07.269
P262 Contraceptive implant induced ulnar neuropathy—J. Kilby, W.L. Merton, A.N. Pandya (School of Pharmacy and Biological Sciences, University of Portsmouth, Queen Alexandra Hospital, Portsmouth, United Kingdom) Significant complications from subdermal insertion of a contraceptive implant in the medial upper arm are rare; a UK Government drug safety update indicating the risk of intravascular insertion was published in 2016.We report the introduction of an implant into the ulnar nerve sheath. Introduction of a contraceptive implant into the medial aspect of the distal left upper arm was followed 5 min later by the patient reporting pins and needles in the arm and tips of the left ring and little fingers. The implant was not palpable. 2 h later loss of sensation was apparent in these fingers; clinical review was unrevealing. Ultrasound suggested the implant was lying between the ulnar nerve and blood vessel in the medial upper arm. At surgery the implant was found within the left ulnar nerve sheath and removed.3 months post surgery the numbness in the little finger had resolved but reduced sensation was still evident over the dorsoulnar hand and distal forearm with hypersensitivity over the ulnar styloid, weakness was not apparent. Nerve conduction studies revealed the left dorsal ulnar sensory NAP was small when compared to the right side (13 vs. 31 microvolts).The left digit 5 sensory NAP was normal amplitude. Motor studies showed mild slowing in the left ulnar nerve around the elbow. While publications and warnings have highlighted the rare occurrence of intravascular insertion, the neurovascular bundle is at risk hence drug company advice to avoid the sulcus between biceps and triceps. This case indicates fascicular damage to the ulnar nerve.
Keywords: Contraceptive implant, Ulnar neuropathy doi:10.1016/j.clinph.2017.07.270
P263 Effect of structural complexities in head modelling on neonatal EEG source analysis—Hamed Azizollahi, Ardalan Aarabi, Fabrice Wallios (INSERM U1105, GRAMFC, Université de Picardie Jules Verne, CHU SUD, Amiens, France) Objective: The accuracy of electroencephalography source reconstruction largely depends on the accuracy of head model, which, in turn, is dependent on the geometry and electrical properties of head tissues. Methods: Based on a MR/CT coregistered images of one neonate we created a highly realistic 6 compartment head model. using a state of art finite element method, we performed numerical simulations to investigate localization errors in dipole source position, orientation and magnitude caused by CSF and fontanel exclusion and GM/WM distinction. Results: Our results showed that exclusion of CSF from the head model caused source localization errors up to 7.5 mm. GM/WM distinction affected widely all sources with localization errors up to 4.3 mm. Exclusion of the fontanels led to localization errors of less
Abstracts / Clinical Neurophysiology 128 (2017) e178–e303
than 4.9 mm specifically for sources located in the areas beneath the fontanels. The majority of sources showed orientation errors up to 24.6°, 19.2° and 17.6°, caused by CSF exclusion, GM/WM distinction and fontanel exclusion, respectively. Discussion: Our results systematically emphasized the importance of the inclusion of the CSF as a highly conductive layer and GM/WM distinction in head model construction. The exclusion of fontanels also led to substantial local localization errors for sources located in the areas beneath the fontanels. Conclusion: In this study we investigated the effect of different head compartments in neonatal head models on EEG source analysis. Significance: Our findings have practical implications for a better understanding of the importance of inaccuracies in head model and their impact on localization of brain electrical activity in neonates. Keywords: EEG, Source localization, CSF, Gray mater, White mater, Head model, Fontanels, Finite element method, Neonates doi:10.1016/j.clinph.2017.07.271
P264 Sjögren’s syndrome presenting with myelitis and without SICCA symptoms—Hacer Erdem Tilki, Sß eyda Bayil (Ondokuz Mayıs University, Department of Neurology, Samsun, Turkey) Sjögren’s syndrome (SS) is a chronic inflammatory disorder of exocrine glands with autoimmune etiology. Sjögren’s syndrome affect the nervous system in approximately 20% of cases. The prevalence of peripheral and central neurological manifestations in Sjögren syndrome are about 15% and 5% respectively. Neurological symptoms may occur before the onset of SICCA symptoms (dry eyes and dry mouth). Anti-Ro/SSA and anti-La/SSB antibodies are present 50–70% of patients with Sjögren syndrome. Patients with SS that have neurological symptoms, only 21% have anti-SSA or anti-SSB antibodies. In this article, we report a patient with SS, presenting as myelitis without any SICCA symptoms and without any Anti-Ro/ SSA and anti-La/SSB antibodies in the sera of patient. Most common peripheral nervous system (PNS) presentations are axonal polyneuropathies (distal axonal sensory and sensorimotor), sensory ganglionopathy, motor neuropathy, small fiber neuropathy, multiple mononeuritis, trigeminal and other cranial neuropathies, autonomic neuropathies, demyelinating polyradiculoneuropathy. The sensory neuropathies constitute the most frequent PNS complication. Central nervous system (CNS) manifestations of Sjögren’s syndrome may affect spinal cord, brain stem, optic nerves, cerebellum, and cerebral hemispheres. CNS involvement is much less common than peripheral nervous system involvement. Transverse myelitis is an inflammatory disorder of the spinal cord that presents acutely. The presence of sensorial axonal polyneuropathy and longitudinally extensive transverse myelitis that spans the servical and thoracic spinal cord led us thinking about SS. The positive Schirmer’ test and lip biopsy supported the diagnosis of SS. So, it is important to consider SS in differential diagnosis even if there is no SICCA syndrome or even if autoantibodies are negative. Keyword: Sjögren syndrome SICCA doi:10.1016/j.clinph.2017.07.272
P265 Correlation of thyroid function disturbances and amyotrophic lateral sclerosis syndrome—Tinatin Kherkheulidze 1, Maia Beridze 2, Nana Kvirkvelaia 3, Omar Samushia 3, Tsira
e263
Manjgaladze 2, Nino Khizanishvhili 4, Eka Devidze 2 (1 Tbilisi State Medical University, HTMC Clinic, Neurology/Neurosurgery Department, Tbilisi, GA, United States, 2 Tbilisi State Medical University, First University Clinic, Neurology Department, Tbilisi, GA, United States, 3 Tbilisi State Medical University, Neurology Department, Tbilisi, GA, United States, 4 Petre Sarjishvili Institute of Neurology, Neurology/Neurophysiology Department, Tbilisi, GA, United States) Background: Coexistence of Amyotrophic Lateral Sclerosis Syndrome (ALS-S) with thyroid disturbances is long ago noticed. Though, previous research did not confirm the role of thyroid hormones in ALS-S. Purpose: to research the role of thyroid gland hormones and free radicals in patients with ALS-S. Methods: Totally 52 patients aged 51–67 years with ALS-S investigated neurologically from endemic goiter area of Georgia. ALS was proved by Neuro-MEP-Micro (version 2009) 2-channel portable EMG. Serum levels of thyroxine (FT4), thyroid stimulating hormone (TSH) and antibodies against thyroid peroxidase (anti-TPO) were detected. The hormone levels analyzed by an electrochemiluminescence method on the apparatus Roche E411. Blood free radicals detected by Electron Paramagnetic Resonance Method (EPR). Statistics performed by SPSS-11.0. Results: Neurologically was found spastic-atrophic changes of the limb muscles in each patient. EMG showed signs of motor neurons’ damage. From all ALS-S patients 38 (73%) found to have hypothyroidism (TSH = 14 ± 2.4 mIU/L, FT4 = 1.7 ± 0.8 ug/dL, antiTPO = 35 ± 5.5 IU/ml); 14 patients (27%) diagnosed as Hashimoto’s thyroiditis (TSH = 11 ± 2.6 mIU/L, FT4 = 2.6 ± 0.7 ug/dL, antiTPO = 300 ± 45.5 IU/ml). Blood lypoperoxiradical (LOO-) was detected in all ALS-S patients. Positive correlation was found between the blood data of anti-TPO and blood data of LOO-. All patients were given appropriate treatment for thyroid disturbances. After 6 months treatment patients’ health was clinically improved, increased volume of innervation by EMG. Conclusion: According to the present study autoimmunity definitely assists to the promotion of free radical pathology in ALS-S and investigations in this direction should be continued. Keywords: EMG, Amyotrophic lateral sclerosis, Thyroid function disturbances, Free radicals doi:10.1016/j.clinph.2017.07.273
P266 Periodics lateralized épileptiform discharges recorded in a centro-pontic myelinolysis, A case report—Fatima Zohra Benchohra (Medecine Faculty of Mostaganem, Physiology Laboratory, Mostaganem, Algeria) Objectives: For some authors, the PLEDs are the EEG expression of a dynamic physiopathological state in which an unstable neurobiological process creates a critical-intercritical continum in relation to the nature of the underlying neuro-neuronal damage, Preexisting ability of the patient to develop epileptic seizures and the coexistence of metabolic disorder [1,2]. We report the case of a young patient with centro-pontic myelinolysis in whom PLEDS were recorded. Materials and methods: Observation: a 25-year-old patient with no medical history, hospitalized in the internal medicine department for management of acute renal failure (ARI), cytolysis, severe hyponatremia, over 18 weeks pregnancy Of amenorrhea, poisoning with thistle algae was strongly suspected.