Neurology resident EEG training in Europe

OBJECTIVE: To detail current European EEG education practices and compare European and U.S. EEG teaching systems. METHODS: A 19-question online survey focused on EEG clinical practices and residency training was emailed to all 47 European Academy of Neurology Societies. RESULTS: Thirty-two (68 %) out of the 47 Societies completed the survey. In half of countries, general neurologists are either among the providers or the only providers who typically read EEGs. The number of weeks devoted to EEG learning required to graduate ranged from none to 26, and it was expected to be continuous in one country. In most countries (n = 17/32), trainees read \u3e40 EEGs per EEG rotation, and the most commonly interpreted studies are routine and prolonged routine EEGs. Rotations involve clinic/outpatient (90 %), epilepsy monitoring unit/inpatient (60 %), or both (50 %). Roughly half of countries do not use objective measures to assess EEG competency. The most reported educational methods are teaching during EEG rotation and yearly didactics, and the most reported education barriers are insufficient didactics and insufficient EEG exposure. CONCLUSIONS: We suggest neurology educators in Europe, especially in those countries where EEGs are read by general neurologists, consider ensuring that residency EEG learning is mandatory and establishing objective measures in teaching and evaluating competency. SIGNIFICANCE: Similar to the U.S., neurology resident EEG training in Europe is highly variable

Exploring the capability of wireless near infrared spectroscopy as a portable seizure detection device for epilepsy patients

AbstractPurposeNear infrared spectroscopy (NIRS) has proved useful in measuring significant hemodynamic changes in the brain during epileptic seizures. The advance of NIRS-technology into wireless and portable devices raises the possibility of using the NIRS-technology for portable seizure detection.MethodsThis study used NIRS to measure changes in oxygenated (HbO), deoxygenated (HbR), and total hemoglobin (HbT) at left and right side of the frontal lobe in 33 patients with epilepsy undergoing long-term video-EEG monitoring. Fifteen patients had 34 focal seizures (20 temporal-, 11 frontal-, 2 parietal-lobe, one unspecific) recorded and analyzed with NIRS. Twelve parameters consisting of maximum increase and decrease changes of HbO, HbR and HbT during seizures (1min before- to 3min after seizure-onset) for left and right side, were compared with the patients’ own non-seizure periods (a 2-h period and a 30-min exercise-period). In both non-seizure periods a 4min moving windows with maximum overlapping were applied to find non-seizure maxima of the 12 parameters. Detection was defined as positive when seizure maximum change exceeded non-seizure maximum change.ResultsWhen analyzing the 12 parameters separately the positive seizure detection was in the range of 6–24%. The increase in hemodynamics was in general better at detecting seizures (15–24%) than the decrease in hemodynamics (6–18%) (P=0.02).ConclusionNIRS did not seem to be a suitable technology for generic seizure detection given the device, settings, and methods used in this study. There are still several challenges to overcome before the NIRS-technology can be used as a home-monitoring seizure detection device

Absence-to-bilateral-tonic-clonic seizure: A generalized seizure type.

OBJECTIVE: To test the hypothesis that absence seizures can evolve to generalized tonic-clonic seizures, we documented electroclinical features of this novel seizure type. METHODS: In 4 large video-EEG databases, we identified recordings of seizures starting with impaired awareness that, without returning to baseline interictal state, evolved to generalized tonic-clonic seizures. We extracted the detailed semiologic and electrographic characteristics of these seizures, and we documented the clinical background, diagnoses, and therapeutic responses in these patients. RESULTS: We identified 12 seizures from 12 patients. All seizures started with a period of impaired awareness and bursts of generalized spike or polyspike and slow-wave discharges, the hallmark of absence seizures. Without returning to baseline, the nonmotor (absence) phase was followed by tonic-clonic convulsions. We called this novel generalized seizure type absence-to-bilateral-tonic-clonic seizure. Most patients had idiopathic generalized epilepsies, although with a high incidence of unusual features and poor therapeutic response. CONCLUSIONS: Absence-to-bilateral-tonic-clonic seizures are a novel generalized seizure type. Clinicians should be aware of this seizure for correctly diagnosing patients. This novel seizure type may further elucidate generalized ictogenesis

Spike count and morphology in the classification of epileptiform discharges

Purpose: The purpose of this study is to investigate the impact of Bergen Epileptiform Morphology Score (BEMS) and interictal epileptiform discharge (IED) candidate count in EEG classification. Methods: We included 400 consecutive patients from a clinical SCORE EEG database during 2013–2017 who had focal sharp discharges in their EEG, but no previous diagnosis of epilepsy. Three blinded EEG readers marked all IED candidates. BEMS and IED candidate counts were combined to classify EEGs as epileptiform or non-epileptiform. Diagnostic performance was assessed and then validated in an external dataset. Results: Interictal epileptiform discharge (IED) candidate count and BEMS were moderately correlated. The optimal criteria to classify an EEG as epileptiform were either one spike at BEMS > = 58, two at > = 47, or seven at > = 36. These criteria had almost perfect inter-rater reliability (Gwet’s AC1 0.96), reasonable sensitivity of 56–64%, and high specificity of 98–99%. The sensitivity was 27–37%, and the specificity was 93–97% for a follow-up diagnosis of epilepsy. In the external dataset, the sensitivity for an epileptiform EEG was 60–70%, and the specificity was 90–93%. Conclusion: Quantified EEG spike morphology (BEMS) and IED candidate count can be combined to classify an EEG as epileptiform with high reliability but with lower sensitivity than regular visual EEG review.publishedVersio

Web-based decision support system for patient-tailored selection of antiseizure medication in adolescents and adults: An external validation study

Antiseizure medications (ASMs) should be tailored to individual characteristics, including seizure type, age, sex, comorbidities, co-medications, drug allergies, and child-bearing potential. We previously developed a web-based algorithm for patient-tailored ASM selection to assist healthcare professionals in prescribing medication using a decision support application (https://epipick.org). In this validation study, we used an independent dataset to assess whether ASMs recommended by the algorithm are associated with better outcomes than ASMs considered less desirable by the algorithm. Four hundred and twenty-five consecutive patients with newly diagnosed epilepsy were followed for at least one year after starting an ASM chosen by their physician. Patient characteristics were fed into the algorithm, blinded to the physician´s ASM choices and outcome. The algorithm recommended ASMs, ranked in hierarchical groups, with Group-1 ASMs labelled as best option for that patient. We evaluated retention rates, seizure-freedom rates and adverse effects leading to treatment discontinuation. Survival analysis contrasted outcomes between patients who received favored drugs and those who received lower ranked drugs. Propensity score matching corrected for possible imbalances between the groups. ASMs classified by the algorithm as best options had higher retention-rate (79.4% vs. 67.2%; p=0.005), higher seizure freedom rate (76.0% vs. 61.6%; p=0.002), and lower rate of discontinuation due to adverse effects (12.0% vs. 29.2%; p<0.001) than ASMs ranked less desirable by the algorithm. Use of the freely available decision-support system is associated with improved outcomes. This drug-selection application can provide valuable assistance to healthcare professionals prescribing medication for individuals with epilepsy