Eeg microstate analysis and its clinical relations in patients with disorders of consciousness

Bilinç Bozuklukları olan hastalar; koma, vejetatif durum ve minimal bilinç durumu olmak üzere, üç ana durumda sınıflandırılırlar. Bu hastalarda, davranış testleri, sınırlamaları olsa da tanı ve prognoz için altın standarttır. Bununla birlikte, yatakbaşı klinik değerlendirmenin zorlukları vardır; uzmanlık gerektirir ve değerlendiricinin öznelliğine bağlı olabilir. Bu nedenle vejetatif durum ve minimal bilinç durumu hastalarının doğru teşhisine izin veren nesnel ölçümlere ihtiyaç vardır. Farklı nörogörüntüleme ve nörofizyolojik araçların bu amaçla kullanımları bir araştırma konusudur. Mikrodurum analizi, elektrot dizisi üzerindeki elektriksel potansiyellerin topografik haritalarını ve bu topografilerin zamansal evrimini analiz eden mekansal-zamansal bir kantitatif EEG analizi yöntemidir. Bu yöntemde, çok kanallı EEG verileri esasen bir dizi elektriksel alan topografisi olarak kabul edilip analiz edilir. Mikrodurum analizi vejetatif durum ve minimal bilinç durumu hastalarının doğru teşhis edilmesine olanak sağlayarak farklı bilinç durumlarındaki, beynin dinlenim durumu aktivitelerinin araştırılmasında başarılı olabileceğini düşündüğümüz, umut verici bir yöntemdir. Ayrıca, bu tür analizler, farklı şiddetlerde bilinç bozukluğu durumlarına sahip hastaların dinlenim durumu aktivitelerindeki önemli farklılıkları anlamamıza ve davranışsal testlerle tespit edemediğimiz farkındalık seviyelerini tespit etmemize de yardımcı olabilir. Bu yüzden biz de, Bilinç Bozuklukları olan hastaların dinlenim durum EEG'lerini mikrodurum analizi üzerinden değerlendirmeyi ve klinik değerlendirme ölçekleriyle mikrodurum parametrelerini karşılaştırmayı amaçladık. Prospektif gözlemsel olan çalışmamıza Bilinç Bozuklukları tanısı almış 30 hasta dahil edildi. Çalışmamıza hasta grupla uyumlu yaş ve cinsiyet ortalamasına sahip 18 adet sağlıklı bireyin daha önce alınmış EEG verisi kontrol grubu olarak dahil edildi. Hastalara davranış ölçekleri uygulanarak klinik değerlendirmeleri sağlandı. EEG çekimleri de mikrodurum analizi ile kantitatif olarak değerlendirildi ve istatistiksel olarak karşılaştırıldı. Bilinç Bozuklukları hastalarının dinlenim durumu EEG'lerinin mikrodurum analizini yaptığımız bu çalışmamızda, mikrodurum parametreleri ile (özellikle Mikrodurum D) hastalığın şiddeti arasında ilişkiyi başarılı bir şekilde saptadık. Lehmann tarafından düşüncenin atomları olarak sunulan mikrodurumlardan mikrodurum D, bilinçliliği yansıtan en iyi parametre olarak tespit edildi. Çalışmamız bu alandaki yapılan az sayıda çalışmadan biridir ve bu yönüyle literatüre ışık tutmaktadır. Tekrarlanan EEG'ler ile Mikrodurum D'nin parametre değişimlerinin değerlendirilmesi, hastanın takibinde kullanılabilir klinik bir işaret olabilir. İleride Bilinç Bozuklukları hastalarının tayini, takibi ve tedavi yanıtlarının izlenmesinde mikrodurum analizi güçlü bir yöntem olmaya aday gibi görünmektedir. Gelecekte uzunlamasına takiplerle birlikte yapılacak yeni çalışmalara ve verilerimizin doğrulanmasına ihtiyaç vardır.Patients with Disorders of Consciousness; It is classified into three main states: coma, vegetative state, and minimally consciousness state. In these patients, behavioral testing is the gold standard for diagnosis and prognosis, although it has limitations. However, bedside clinical assessment is difficult, requires expertise, and may depend on the subjectivity of the practitioner. Therefore, there is a need for objective measurements that allow accurate diagnosis of vegetative state and minimally consciousness state patients. The use of different neuroimaging and neurophysiological tools for this purpose is a research topic. Microstate analysis is a spatial-temporal quantitative EEG analysis method that analyzes topographic maps of electrical potentials on the electrode array and the temporal evolution of these topographies. In this method, multi-channel EEG data is essentially considered and analyzed as a series of electrical field topography. Microstate analysis is a promising method that we think can be successful in investigating the resting state networks of the brain in different states of consciousness by enabling the correct diagnosis of vegetative state and minimally consciousness state patients. In addition, such analyzes can help us to understand the significant differences in the resting state activities of patients with different degrees of impaired consciousness and to detect levels of awareness that we cannot detect with behavioral tests. Therefore, we aimed to evaluate the resting state EEGs of patients with Disorders of Consciousness through microstate analysis and to compare clinical assessment scales and microstate parameters. Thirty patients diagnosed with Disorders of Consciousness were included in our prospective observational study. EEG data of 18 healthy individuals with an average age and gender compatible with the patient group were included in our study as the control group. Behavior scales were tested on the patients and their clinical evaluations were provided. EEG recordings were also evaluated quantitatively by microstate analysis and compared statistically. In this study, in which we conducted microstate analysis of resting state EEGs of patients with Disorders of Consciousness, we successfully determined the relationship between microstate parameters (especially Microstate D) and the severity of the disease. Among the microstates presented by Lehmann as atoms of thought, microstate D was identified as the best parameter reflecting consciousness. Our study is one of the few studies in this field and sheds light on the literature in this respect. Evaluation of parameter changes of Microstate D with repeated EEGs can be a clinical sign that can be used in the follow-up of the patient. Microstate analysis seems to be a strong candidate for the identification, follow-up and treatment response of patients with Disorders of Consciousness in the future. Future studies with longitudinal follow-ups and confirmation of our data are needed

Therapeutic role of repetitive transcranial magnetic stimulation in Alzheimer's and Parkinson's disease: Electroencephalography microstate correlates

Introduction: The microstate analysis is a method to convert the electrical potentials on the multi-channel electrode array to topographical electroencephalography (EEG) data. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive method that can modulate brain networks. This study explores the pathophysiological changes through microstate analysis in two different neurodegenerative diseases, Alzheimer’s (AD) and Parkinson’s disease (PD), characterized by motor and cognitive symptoms and analysis the effect of rTMS on the impaired cognitive and motor functions. Materials and Methods: We included 18 AD, 8 PD patients, and 13 age-matched controls. For both groups, we applied 5 Hz rTMS on the left pre-SMA in PD patients while 20 Hz rTMS on the left lateral parietal region in AD patients. Each patient was re-evaluated 1 week after the end of the sessions, which included a detailed clinical evaluation and measurement of EEG microstates. Results: At the baseline, the common findings between our AD and PD patients were altered microstate (MS) B, MS D durations and transition frequencies between MS A–MS B, MS C–MS D while global explained variance (GEV) ratio and the extent and frequency of occurrence of MS A, MS B, and MS D were separately altered in AD patients. Although no specific microstate parameter adequately differentiated between AD and PD patients, we observed significant changes in MS B and MS D parameters in PD patients. Further, we observed that Mini-Mental State Examination (MMSE) performances were associated with the transition frequencies between MS A–MS B and MS C–MS D and GEV ratio. After left parietal rTMS application, we have observed significantly increased visual memory recognition and clock drawing scores after left parietal rTMS application associated with improved microstate conditions prominent, especially in the mean duration of MS C in AD patients. Also, pre-SMA rTMS resulted in significant improvement in motor scores and frequency of transitions from MS D to MS C in PD patients. Conclusion: This study shows that PD and AD can cause different and similar microstate changes that can be modulated through rTMS, suggesting the role of MS parameters and rTMS as a possible combination in monitoring the treatment effect in neurodegenerative diseases

Bu müzik nereden geliyor? Müzikal halüsinoz olgu sunumu

GİRİŞ VE AMAÇ: Müzikal halüsinasyonlar (MH), harici akustik uyaranın yokluğunda sürekli veya aralıklı müzik tonları ve melodiler duyulan işitsel halüsinasyonların özel bir türüdür. Bu durum Müzikal Kulak Sendromu, Müzikal Halüsinoz, Oliver Sacks sendromu ve İşitsel Charles Bonnet sendromu gibi isimlerle bilinmektedir. İdiyopatik ve semptomatik olmak üzere iki gruba ayrılırlar. Risk faktörleri arasında işitme kaybı, ileri yaş, beyin hastalığı, kadın cinsiyet ve sosyal izolasyon sayılabilir. Bu yazıda hafif işitme kaybı ve anormal ’de aktivitesiyle ilişkili müzikal halüsinasyonları olan ve oral lamotrijinle transdermal rivastigmin tedavisine yanıt veren yaşlı bir kadın olgu sunulmaktadır

EEG-Meta-Microstates: Towards a More Objective Use of Resting-State EEG Microstate Findings Across Studies.

Over the last decade, EEG resting-state microstate analysis has evolved from a niche existence to a widely used and well-accepted methodology. The rapidly increasing body of empirical findings started to yield overarching patterns of associations of biological and psychological states and traits with specific microstate classes. However, currently, this cross-referencing among apparently similar microstate classes of different studies is typically done by "eyeballing" of printed template maps by the individual authors, lacking a systematic procedure. To improve the reliability and validity of future findings, we present a tool to systematically collect the actual data of template maps from as many published studies as possible and present them in their entirety as a matrix of spatial similarity. The tool also allows importing novel template maps and systematically extracting the findings associated with specific microstate maps from ongoing or published studies. The tool also allows importing novel template maps and systematically extracting the findings associated with specific microstate maps in the literature. The analysis of 40 included sets of template maps indicated that: (i) there is a high degree of similarity of template maps across studies, (ii) similar template maps were associated with converging empirical findings, and (iii) representative meta-microstates can be extracted from the individual studies. We hope that this tool will be useful in coming to a more comprehensive, objective, and overarching representation of microstate findings

Transient alien hand syndrome in ischemic lesions of the corpus callosum: A report of 3 cases

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Factors affecting prognosis in Hypoxic Encephalopathy patients followed-up in intensive care unit

Öz:Amaç: Kardiyak arrest sonrasında gelişen hipoksik ensefalopati (HE) ciddi nörolojik sekel ve ölüme neden olabilen bir klinik tablodur. HE’li hastalarda prognozu belirlemek, takip ve uzun vadede geliştirilecek tedaviler açısından önemlidir. Bu çalışmada amacımız HE tanısı almış hastalarda yaş, cinsiyet, hipotermi uygulamasının, beyin manyetik rezonans görüntüleme de (MRG) lezyon yerinin, epileptik nöbet varlığının ve elektroensefalografi (EEG) bulgularının prognoz üzerine etkilerini araştırmaktır. Gereç ve Yöntem: Erişkin yoğun bakım ünitesi hasta kayıtları retrospektif olarak incelendi. HE tanısı almış 194 hasta çalışmaya dahil edildi. Hastaların 118’i erkek (%60,8), 76’sı (%39,2) kadındı. Sağ kalanlar ve eksitus olanlar belirlendi. Hipotermi uygulananlar, beyin MRG bulguları (kortikal ve/veya subkortikal lezyon), epileptik nöbet varlığı (miyoklonik, jeneralize, fokal) ve EEG bulguları (epileptik aktivite, status, jeneralize yavaşlama) kaydedildi. Bulgular: Yaş ortalaması 59,46±1,71 (18-89) idi. Yetmiş altı (%39,2) hastaya hipotermi uygulandı. Yüz yedi (%55,2) hasta eksitus oldu. Yaşlı hastaların eksitus olma oranı anlamlı olarak daha yüksekti (p0,05). Sonuç: Çalışmamıza dahil edilen hastaların yaklaşık yarısı eksitus olmuştur. Yaşlı ve beyin MRG’de multiple lezyonu olanların sağkalım oranı düşüktür.Objectives: Hypoxic encephalopathy (HE) after cardiac arrest is a clinical condition that can cause severe neurological sequelae and death. It is important to determine the prognosis in patients with HE for follow up and developing future treatments in the long term. Our aim was to investigate the effects of age, gender, hypothermia, lesion site in brain magnetic resonance imaging (MRI), seizure and electroencephalography (EEG) findings on prognosis in patients with the diagnosis of HE. Materials and Methods: The data of the adult intensive care unit was evaluated retrospectively. A total of 194 patients with HE were included into the study. One hundred and eighteen (60.8%) of the patients were male and 76 (39.2%) were female. The survivors and those who died were identified. Hypothermia therapy, brain MRI findings (cortical and/or subcortical lesion), presence of seizures (myoclonic, generalized, focal) and EEG findings (epileptic activity, status, generalized slowing) were recorded. Results: The mean age was 59.46±1.71 (18-89). Seventy-six (39.2%) patients underwent hypothermia. One hundred and seven (55.2%) patients died. The rate of exitus in elderly patients was significantly higher (p0.05). Conclusion: Approximately half of the patients included in our study died. The survival rate of the elderly patients and the patients with multiple lesions in brain MRI was lo

Acute Stroke Management in Türkiye: Intravenous Tissue Plasminogen Activator and Thrombectomy NöroTek: Türkiye Neurology Single Day Study

Objective: To reveal the profile and practice in patients with acute stroke who received intravenous tissue plasminogen activator (IV tPA) and/or neuro-interventional therapy in Türkiye. Materials and Methods: On World Stroke Awareness Day, May 10, 2018, 1,790 patients hospitalized in 87 neurology units spread over 30 health regions were evaluated retrospectively and prospectively. Results: Intravenous tPA was administered to 12% of 859 cases of acute ischemic stroke in 45 units participating in the study. In the same period, 8.3% of the cases received neurointerventional treatment. The rate of good prognosis [modified Rankin score (mRS) 0–2] at discharge was 46% in 83 patients who received only IV tPA [age: 67 ± 12 years; National Institutes of Health Stroke Scale (NIHSS): 12 ± 6; hospital stay, 24 ± 29 days]; 35% in 51 patients who underwent thrombectomy (MT) alone (age: 64 ± 13 years; NIHSS: 14.1 ± 6.5; length of hospital stay, 33 ± 31 days), 19% in those who received combined treatment (age: 66 ± 14 years; NIHSS: 15.6 ± 5.4; length of hospital stay, 26 ± 35 days), and 56% of 695 patients who did not receive treatment for revascularization (age: 70 ± 13 years; NIHSS: 7.6 ± 7.2; length of hospital stay, 21 ± 28 days). The symptom-to-door time was 87 ± 53 minutes in the IV treatment group and 200 ± 26 minutes in the neurointerventional group. The average door-to-needle time was 66 ± 49 minutes in the IV tPA group. In the neurothrombectomy group, the door-to-groin time was 103 ± 90 minutes, and the TICI 2b-3 rate was 70.3%. In 103 patients who received IV tPA, the discharge mRS 0–2 was 41%, while the rate of mRS 0–1 was 28%. In 71 patients who underwent neurothrombectomy, the mRS 0–2 was 31% and mRS 0–1 was 18%. The door-to-groin time was approximately 30 minutes longer if IV tPA was received (125 ± 107 and 95 ± 83 minutes, respectively). Symptomatic bleeding rates were 4.8% in IV recipients, 17.6% among those who received only MT, and 15% in combined therapy. Globally, the hemorrhage rate was 6.8% in patients receiving IV tPA and 16.9% in MT. Conclusion: IV thrombolytic and neurointerventional treatment applications in acute ischemic stroke in Türkiye can provide the anticipated results. Heterogeneity has begun to be reduced in our country with the dissemination of the system indicated by the “Directive on Health Services to be Provided to Patients with Acute Stroke.”. © Copyright 2023 by the Turkish Neurological Society / Turkish Journal of Neurology published by Galenos Publishing House

Gastrostomy in hospitalized patients with acute stroke: "NoroTek" Turkey point prevalence study subgroup analysis

Objective: Nutritional status assessment, dysphagia evaluation and enteral feeding decision are important determinants of prognosis in acute neurovascular diseases. Materials and Methods: NöroTek is a point prevalence study conducted with the participation of 87 hospitals spread across all health sub regions of Turkey conducted on 10-May-2018 (World Stroke Awareness Day). A total of 972 hospitalized neurovascular patients [female: 53%, age: 69±14; acute ischemic stroke in 845; intracerebral hematoma (ICH) in 119 and post-resuscitation encephalopathy (PRE) in 8] with complete data were included in this sub-study. Results: Gastrostomy was inserted in 10.7% of the patients with ischemic stroke, 10.1% of the patients with ICH and in 50% of the patients with PRE. Independent predictors of percutaneous endoscopic gastrostomy (PEG) administration were The National Institutes of Health Stroke Scale score at admission [exp (β): 1.09 95% confidence interval (CI): 1.05-1.14, per point] in ischemic stroke; and mechanical ventilation in ischemic [exp (β): 6.18 (95% CI: 3.16-12.09)] and hemorrhagic strokes [exp (β): 26.48 (95% CI: 1.36-515.8)]. PEG was found to be a significant negative indicator of favorable (modified Rankin’s scale score 0-2) functional outcome [exp (β): 0.032 (95% CI: 0.004-0.251)] but not of in-hospital mortality [exp (β): 1.731 (95% CI: 0.785-3.829)]. Nutritional and swallowing assessments were performed in approximately two-thirds of patients. Of the nutritional assessments 69% and 76% of dysphagia assessments were completed within the first 2 days. Tube feeding was performed in 39% of the patients. In 83.5% of them, tube was inserted in the first 2 days; 28% of the patients with feeding tube had PEG later. Conclusion: The NöroTek study provided the first reliable and large-scale data on key quality metrics of nutrition practice in acute stroke in Turkey. In terms of being economical and accurate it makes sense to use the point prevalence method.Amaç: Akut nörovasküler hastalıklarda nütrisyonel durum ve disfaji değerlendirmesi ve enteral beslenme kararı önemli prognoz belirleyicilerindendir. Gereç ve Yöntem: NöroTek, 10 Mayıs 2018’de (Dünya İnme Farkındalık Günü) Türkiye’nin tüm sağlık alt bölgelerine yayılmış 87 hastanenin katılımıyla gerçekleştirilen bir nokta prevalans çalışmasıdır. Hastanede yatan ve bu alt çalışma için toplanan verisi tam olan toplam 972 nörovasküler hasta (kadın: %53, yaş: 69±14 yıl; 845’i akut iskemik inme; 119’u intraserebral hematom ve 8’i post-resüsitasyon ensefalopatisi) analiz edildi. Bulgular: Gastrostomi iskemik inmeli hastaların %10,7, intraserebral kanamalıların %10,1 ve post-resusitasyon ensefalopatisi olanların %50’sine uygulanmıştır. Perkütan endoskopik gastrostomi (PEG) gereksiniminin bağımsız belirleyicileri, iskemik inme grubunda kabul NIHSS [exp (β): 1,09, %95 güven aralığı (GA): 1,05-1,14, puan başına] ile hem iskemik hem de hemorajik inmelerde mekanik ventilasyon uygulanmış olmasıdır [iskemik için: exp (β): 6,18, %95 GA: 3,16- 12,09] ve hemorajik inme için: [exp (β): 26,48, 95% GA: 1,36-515,8]. İnme olgularında PEG uygulaması hastane içi mortalite için bağımsız belirleyici değildi [exp (β): 1,731, 95% GA: 0,785-3,829]. Ancak, PEG uygulanmış olması taburculuk esnasında iyi prognoza (modifiye Rankin skoru 0-2) sahip olabilme için anlamlı bir negatif etmen olarak bulundu [exp (β): 0,032, %95 GA: 0,004-0,251]. Hastanede yatan nörovasküler hastaların yaklaşık üçte ikisinde malnütrisyon ve yutma bozukluğu açısından değerlendirme yapılmıştı. Nutrisyonel status değerlendirmesinin %69’u ve disfaji değerlendirmesinin %76’sı ilk 48 saat içinde gerçekleştirilmişti. Tüple enteral nütrisyon uygulama oranı %39’du. Beslenme tüplerinin %83,5’i ilk 2 gün içinde yerleştirilirken beslenme tüpü olan hastaların %28’ine daha sonra PEG açılmıştı. Sonuç: NöroTek çalışması ile Türkiye’de hastanede yatan akut inme hastalarında nutrisyonel uygulamaların temel kalite ölçütlerine ilişkin ilk güvenilir ve büyük ölçekli veri sağlanmıştır. Ekonomik olması ve doğruluğu açısından nokta yaygınlık yönteminin bu tip verilerin temini için daha fazla kullanılması mantıklıdır