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S29. rTMS application in disorders of consciousness
Abstracts / Clinical Neurophysiology 129 (2018) e142–e212
describe the population according to a periodic pattern (PP) and not periodic (NoPP), and compared characteristics between them. We estimate survival during hospitalization at ICU using the Kaplan– Meier method and compared survival between groups with a log rank test. Results: We included 60 patients, mean age was 57 years (SD 18), 41.7% (25) were female. The median stay in ICU was 28 days (IQR 11.5-48). Thirty percent (12) were classified as PP and 70% (48) as NoPP. Comparing baseline characteristics between groups PP vs NoPP, female proportion was (72.2% vs 28.6%; p = 0.01), age (66.1 vs 56.5 years; p = 0.23), CCI (1.5 vs 1; p = 0.58), etiology (intra-axial compressive injuries 11.1% vs destructive injuries 19%; p = 0.46) and time from ICU admission to first EEG (3 vs 4; p = 0.81), respectively. Survival in ICU was for PP vs NoPP was 61.29% (CI95% 33.3– 80.4) vs 79.4% (CI95% 61.6–89.6) p = 0.11, respectively. Functional prognostic at discharge measured as GOS 6 2 was 50% (9) and 38.1% (16) p = 0.41 for PP vs NoPP. Conclusion: A lower in hospital survival was observed in patients admitted to the ICU with a periodic electroencephalographic pattern and a worse functional prognosis compared with patients with nonperiodic pattern. Although this difference is not statistically significant, due to the small sample, we question if pattern detection can define clinical prognosis and mortality in patients at the intensive care unit. doi:10.1016/j.clinph.2018.04.388
S29. rTMS application in disorders of consciousness—Alexandra Poydasheva *, Liudmila Legostaeva, Elizaveta Mochalova, Elena Kremneva, Dmitri Sinitsyn, Dmitri Sergeev, Natalia Suponeva, Julia Ryabinkina, Michael Piradov (Russian Federation) ⇑
Presenting author.
Introduction: There is an unmet need in effective neurorehabilitation methods in chronic disorders of consciousness (DOC). Noninvasive brain stimulation, such as navigated rTMS, is a perspective tool for modulation of the cerebral networks activity in such patients, and resting FMRI, that allows estimating the neural networks activation and interactions, may indicate the target for precise stimulation. Patients with severe brain damage after anoxia or trauma who survived coma, show selective activation of the default mode network (DMN), particularly, gyrus angularis, as the level of consciousness increases. Here, we studied effects of high-frequency navigated rTMS on gyrus angularis as a new approach for the chronic DOC rehabilitation. Methods: We included 10 patients with post-anoxic VS (median age 39.3, mean CRS-R score 5.1); 8 patients with post-anoxic MCS (median age 45.8, mean CRS-R score 14.4); 4 patients with traumatic VS (median age 22.3, mean CRS-R 5.8), and 5 traumatic MCS patients (median age 45.8, mean CRS-R 14.4). EEG revealed no seizure-like electric activity. Individual activation assessed by resting fMRI represented DMN activation including left gyrus angularis area in MCS patients, with no activation of DMN in VS patients. Against the background of standard rehabilitation program (motomed letto IIassisted mechanical therapy, massage, passive joints movements) we provided high-frequency rTMS on the gyrus angularis (10 sessions of stimulation with 20 Hz, 2400 stimulus 90% MT). Consciousness level was assessed with CRS-R scale by the same independent rater before and after stimulation course. Results: CRS-R score increased in the patients with the residual signs of consciousness behavior (MCS). Median increase in CRS-R score after neurorehabilitation course was 2 points. However, we found no change in clinical assessment in the VS cases. No side
e153
effects of the rTMS were observed. Correlation of CRS-r score in permanent disorders of consciousness before and after rTMS course on gyrus angularis. Conclusion: The course of the high-frequency TMS with navigation on gyrus angularis is a potentially effective method of rehabilitation in permanent disorders of consciousness. We obtained clinical effect in states of the minimal signs of consciousness, but not in VS. These results are advisable to continue researches in studies of this new protocol’s effectiveness. The study is supported by Russian Science Foundation grant No. 16-15-00274. doi:10.1016/j.clinph.2018.04.389
S30. Immediate or retarded nerve repair—Clara Nevado *, Juan Pablo Aguado, Antonia Garcia (Spain) ⇑
Presenting author.
Introduction: We presented two cases with complete ulnar nerve section at the very same level, antebrachial region, below branches to flexor digitorum profundus, one with immediate repair and the other with delay repair of about three months. Methods: The delay repair and the immediate repair nerves were at the same month, we make them an EMG at eight weeks from repair and every four weeks until reinnervation took place (motor units seen at abductor digiti minimi). Also echography was done to ensure cubital growing. Age was similar for boths patients, gender: one man (delay) other woman (immediate). Rehabilitation techniques were the same for all of them. Also de the surgeon was the same in all two. Results: Time for reinnervation at the immediate repair was at nine months after the epineural end-to-end repair. Time for reinnervation at the delay repair was five months after a sural nerve graft was used ( eight months after ulnar lesion). Of the two patients the delay repair has had better reinnervation (force 3/5) while the immediate repair ended with 2/5 force and also an ulnar neuroma was seen and removed, months after the nerve reached abductor digiti minimi. Conclusion: As we observed in these particular cases, time is more or less the same in both cases regardless of the technique to repair nerve, probably first is the inflammation phase plus wallerian degeneration, so useful reinervation takes place later, so probably delay repair is not as usefulness as it has been proposed, if it is doing in the right time, after inflammation phase has ended probably avoiding neuroma formation and less endoneural fibrosis, and also we need to search for others ways to avoid inflammation after nerve section to elevate prognosis. doi:10.1016/j.clinph.2018.04.390
S31. Guillain–Barré syndrome outcome at Cipto Mangunkusumo Hospital Jakarta Indonesia—Ahmad Y. Safri *, Ramdinal Avisenna, Luh Ari Indrawati, Fitri Octaviana, Manfaluthy Hakim (Indonesia) ⇑
Presenting author.
Introduction: Erasmus GBS Outcome Score (EGOS) is a model to predict the outcome of patients after GBS. EGOS studies were conducted in well developed countries, which have different patient characteristics and medical facility than in the middle-income country like Indonesia. In the middle-income country, the prognosis
describe the population according to a periodic pattern (PP) and not periodic (NoPP), and compared characteristics between them. We estimate survival during hospitalization at ICU using the Kaplan– Meier method and compared survival between groups with a log rank test. Results: We included 60 patients, mean age was 57 years (SD 18), 41.7% (25) were female. The median stay in ICU was 28 days (IQR 11.5-48). Thirty percent (12) were classified as PP and 70% (48) as NoPP. Comparing baseline characteristics between groups PP vs NoPP, female proportion was (72.2% vs 28.6%; p = 0.01), age (66.1 vs 56.5 years; p = 0.23), CCI (1.5 vs 1; p = 0.58), etiology (intra-axial compressive injuries 11.1% vs destructive injuries 19%; p = 0.46) and time from ICU admission to first EEG (3 vs 4; p = 0.81), respectively. Survival in ICU was for PP vs NoPP was 61.29% (CI95% 33.3– 80.4) vs 79.4% (CI95% 61.6–89.6) p = 0.11, respectively. Functional prognostic at discharge measured as GOS 6 2 was 50% (9) and 38.1% (16) p = 0.41 for PP vs NoPP. Conclusion: A lower in hospital survival was observed in patients admitted to the ICU with a periodic electroencephalographic pattern and a worse functional prognosis compared with patients with nonperiodic pattern. Although this difference is not statistically significant, due to the small sample, we question if pattern detection can define clinical prognosis and mortality in patients at the intensive care unit. doi:10.1016/j.clinph.2018.04.388
S29. rTMS application in disorders of consciousness—Alexandra Poydasheva *, Liudmila Legostaeva, Elizaveta Mochalova, Elena Kremneva, Dmitri Sinitsyn, Dmitri Sergeev, Natalia Suponeva, Julia Ryabinkina, Michael Piradov (Russian Federation) ⇑
Presenting author.
Introduction: There is an unmet need in effective neurorehabilitation methods in chronic disorders of consciousness (DOC). Noninvasive brain stimulation, such as navigated rTMS, is a perspective tool for modulation of the cerebral networks activity in such patients, and resting FMRI, that allows estimating the neural networks activation and interactions, may indicate the target for precise stimulation. Patients with severe brain damage after anoxia or trauma who survived coma, show selective activation of the default mode network (DMN), particularly, gyrus angularis, as the level of consciousness increases. Here, we studied effects of high-frequency navigated rTMS on gyrus angularis as a new approach for the chronic DOC rehabilitation. Methods: We included 10 patients with post-anoxic VS (median age 39.3, mean CRS-R score 5.1); 8 patients with post-anoxic MCS (median age 45.8, mean CRS-R score 14.4); 4 patients with traumatic VS (median age 22.3, mean CRS-R 5.8), and 5 traumatic MCS patients (median age 45.8, mean CRS-R 14.4). EEG revealed no seizure-like electric activity. Individual activation assessed by resting fMRI represented DMN activation including left gyrus angularis area in MCS patients, with no activation of DMN in VS patients. Against the background of standard rehabilitation program (motomed letto IIassisted mechanical therapy, massage, passive joints movements) we provided high-frequency rTMS on the gyrus angularis (10 sessions of stimulation with 20 Hz, 2400 stimulus 90% MT). Consciousness level was assessed with CRS-R scale by the same independent rater before and after stimulation course. Results: CRS-R score increased in the patients with the residual signs of consciousness behavior (MCS). Median increase in CRS-R score after neurorehabilitation course was 2 points. However, we found no change in clinical assessment in the VS cases. No side
e153
effects of the rTMS were observed. Correlation of CRS-r score in permanent disorders of consciousness before and after rTMS course on gyrus angularis. Conclusion: The course of the high-frequency TMS with navigation on gyrus angularis is a potentially effective method of rehabilitation in permanent disorders of consciousness. We obtained clinical effect in states of the minimal signs of consciousness, but not in VS. These results are advisable to continue researches in studies of this new protocol’s effectiveness. The study is supported by Russian Science Foundation grant No. 16-15-00274. doi:10.1016/j.clinph.2018.04.389
S30. Immediate or retarded nerve repair—Clara Nevado *, Juan Pablo Aguado, Antonia Garcia (Spain) ⇑
Presenting author.
Introduction: We presented two cases with complete ulnar nerve section at the very same level, antebrachial region, below branches to flexor digitorum profundus, one with immediate repair and the other with delay repair of about three months. Methods: The delay repair and the immediate repair nerves were at the same month, we make them an EMG at eight weeks from repair and every four weeks until reinnervation took place (motor units seen at abductor digiti minimi). Also echography was done to ensure cubital growing. Age was similar for boths patients, gender: one man (delay) other woman (immediate). Rehabilitation techniques were the same for all of them. Also de the surgeon was the same in all two. Results: Time for reinnervation at the immediate repair was at nine months after the epineural end-to-end repair. Time for reinnervation at the delay repair was five months after a sural nerve graft was used ( eight months after ulnar lesion). Of the two patients the delay repair has had better reinnervation (force 3/5) while the immediate repair ended with 2/5 force and also an ulnar neuroma was seen and removed, months after the nerve reached abductor digiti minimi. Conclusion: As we observed in these particular cases, time is more or less the same in both cases regardless of the technique to repair nerve, probably first is the inflammation phase plus wallerian degeneration, so useful reinervation takes place later, so probably delay repair is not as usefulness as it has been proposed, if it is doing in the right time, after inflammation phase has ended probably avoiding neuroma formation and less endoneural fibrosis, and also we need to search for others ways to avoid inflammation after nerve section to elevate prognosis. doi:10.1016/j.clinph.2018.04.390
S31. Guillain–Barré syndrome outcome at Cipto Mangunkusumo Hospital Jakarta Indonesia—Ahmad Y. Safri *, Ramdinal Avisenna, Luh Ari Indrawati, Fitri Octaviana, Manfaluthy Hakim (Indonesia) ⇑
Presenting author.
Introduction: Erasmus GBS Outcome Score (EGOS) is a model to predict the outcome of patients after GBS. EGOS studies were conducted in well developed countries, which have different patient characteristics and medical facility than in the middle-income country like Indonesia. In the middle-income country, the prognosis