Tele-epileptology Ruhr

$\bf Hintergrund$ Diagnose und Behandlung von Patienten mit Epilepsie oder anderen anfallsartig auftretenden Symptomen erfordert in manchen Situationen Spezialistenwissen. Um dieses auch Abteilungen ohne eigene spezialisierte Epileptologen zur Verfügung stellen zu können, wurde im Rahmen des Modellprojektes Tele-Epileptologie Ruhr (TE Ruhr) eine telemedizinische Infrastruktur zum patientenbezogenen Austausch zwischen allgemeinneurologischen Akutkliniken bzw. ausländischen Epilepsiezentren und der Ruhr-Epileptologie, Bochum, geschaffen. $\bf Methoden$ Die TE Ruhr ist eine multizentrische, prospektive Pilotstudie. Die telemedizinische Kommunikation inklusive Austausch von Untersuchungsdaten läuft über ein Webtool (rein webbasierte Anwendung). Es wurden Kliniken angeschlossen, mit denen bereits im Vorfeld eine Kooperation bestand. Patienten wurden nach Maßgabe der behandelnden Ärzte nach schriftlicher Einwilligung eingeschlossen. Die Zwischenevaluation wurde mit verantwortlichen Ärzten in den Kliniken per Fragebogen im Rahmen eines Telefoninterviews erstellt. $\bf Ergebnisse$ Zum Zeitpunkt der Befragung waren 8 regionale und 4 internationale Partnerkliniken angeschlossen. Die befragten Ärzte bewerten das Gesamtprojekt inklusive der technischen Realisierung mit einer Durchschnittsnote von 2,1 (1–4 auf einer Schulnotenskala von 1–6). Alle Befragten sehen einen Nutzen der TE Ruhr eher für Einzelfälle als für Routinevorstellungen. Wichtig für die Teilnehmer ist eine einfache und schnelle Bedienung der Konsilplattform. $\bf Diskussion$ Die Zwischenanalyse des Modellprojekts TE Ruhr hat gezeigt, dass die technische Etablierung einer teleepileptologischen Konsilplattform erfolgreich möglich ist. Die Ergebnisse machen über das konkrete Projekt hinaus deutlich, wo technische und organisatorische Herausforderungen telemedizinischer Anwendungen liegen und wie diesen begegnet werden kann.$\bf Background$ The diagnosis and treatment of patients with epilepsy or other paroxysmal neurological symptoms require specialist input in some situations. In order to make this available to departments without specialized epileptologists, a telemedical infrastructure was created for patient-related exchange between general neurological departments or foreign epilepsy centers and the Ruhr Epileptology, Bochum, Germany within the model project Tele-epileptology Ruhr (TE Ruhr). $\bf Methods$ The TE Ruhr is a multicenter, prospective pilot study. The telemedical communication including exchange of original technical data (e.g. MRI, EEG) runs via a web tool (purely web-based application). Departments with a pre-existing cooperation were invited to participate. Patients were included after written consent was obtained from the treating physicians. The interim evaluation was conducted with responsible physicians in the participating departments by questionnaire during a telephone interview. $\bf Results$ At the time of the survey eight regional and four international departments were affiliated. The interviewed physicians rated the overall project, including the technical implementation, with an average grade of 2.1 (range 1–4 on a scale from 1 very good to 6 very poor). All respondents saw a benefit of TE Ruhr for individual cases rather than for routine presentations. Important for the participants was a simple and fast handling of the consultation platform. $\bf Discussion$ The interim analysis of the model project TE Ruhr has shown that the technical establishment of a tele-epileptological consultation platform is successfully possible. The results illustrate the technical and organizational challenges of telemedical applications and how these can be met, beyond this particular project

Practical management of epileptic seizures and status epilepticus in adult palliative care patients

In terminally ill patients, paroxysmal or episodic changes of consciousness, movements and behavior are frequent. Due to ambiguous appearance, the correct diagnosis of epileptic seizures (ES) and non-epileptic events (NEE) is often difficult. Treatment is frequently complicated by the underlying condition, and an approach indicated in healthier patients may not always be appropriate in the palliative care setting. This article provides recommendations for diagnosis of ES and NEE and treatment options for ES in adult palliative care patients, including aspects of alternative administration routes for antiepileptic drugs such as intranasal, subcutaneous, or rectal application

Suggestive seizure induction for inpatients with suspected psychogenic nonepileptic seizures

$\bf Objective$ To determine the utility of suggestive seizure induction for inpatient work-up of suspected psychogenic nonepileptic seizures (PNES). $\bf Methods$ Prospective study of epilepsy center inpatient admissions with suspected PNES. Patients were randomized to undergo suggestive induction first (group A) and then, if necessary, long-term video-electroencephalography (EEG) monitoring, or vice versa (group B). Diagnostic pathways were compared. Potential clinical predictors for diagnostic success were evaluated. $\bf Results$ Length of in-hospital stay did not significantly differ between groups. Suspicion of PNES was confirmed in 43 of 77 (56%) patients, evenly distributed between group A (22 of 39) and group B (21 of 38). In nine patients, recorded habitual seizures were epileptic and in 25 cases, no diagnostic event could be recorded. Diagnosis of PNES was ascertained primarily by recording a typical seizure through suggestive induction in 24 patients and through long-term monitoring in 19 patients. In group A (induction first), monitoring was not deemed necessary in 21% of cases. In group B (monitoring first), 13% would have remained inconclusive without suggestive induction. Patients who reported triggers to their habitual seizures were not more likely to have spontaneous or provoked PNES during monitoring or suggestive inducion, respectively. Patients with subjective seizure prodromes (auras) were significantly more likely to have a PNES during suggestive induction than those without (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.1-10.4). There was no significant difference in seizure frequency between patients with spontaneous PNES during long-term monitoring and those with nondiagnostic monitoring sessions. $\bf Significance$ Our results support the notion that suggestive seizure induction can reduce the number of inconclusive inpatient workups, and can obviate resource-intensive long-term monitoring in one fifth of cases. Patients who are aware of prodromes might have a higher chance of having seizures induced through suggestion

Telemedicine in epilepsy care

Telemedizinische Arzt-zu-Arzt-Anwendungen in der Epilepsieversorgung können helfen, die spezielle Expertise von neurologischen oder pädiatrischen EpileptologInnen flächendeckend vorzuhalten, da sie es ermöglichen, medizinische Leistung über Distanzen hinweg zu erbringen. Sowohl national als auch international werden hierzu verschiedene Lösungsansätze entwickelt. Herausforderungen begegnet man auf organisatorischer, technischer, rechtlicher und ökonomischer Ebene, sodass die langfristige Perspektive der einzelnen aktuellen Lösungsansätze noch unklar ist. Letztendlich bedarf es der Entwicklung von Betriebsmodellen, bei denen alle Akteure (Konsilgeber, Konsilanforderer, Patient, Kostenträger, Betreiber der telemedizinischen Plattform und ggf. auch die jeweilige Fachgesellschaft) jeweils den spezifischen Nutzen und die Risiken abwägen.Telemedical doc-to-doc applications in epilepsy care can help to provide the special expertise of adult or pediatric epileptologists area wide, as they make it possible to provide medical services across spatial distances. Various solutions are being developed both nationally and internationally for this purpose; however, there are organizational, technical, legal and economic challenges. The long-term perspective of the various current approaches is unclear. Ultimately, business models will have to be developed in which all players (consultation providers and requesting physician, patients, health insurers, operators of telemedical platforms and, if necessary, the respective professional associations) weigh up the specific benefits and risks

Telemedicine in epilepsy care

$\bf Hintergrund$ In den vergangenen 10 Jahren wurden an verschiedenen Epilepsiezentren in Deutschland (Bochum, Erlangen, Greifswald, Berlin Brandenburg, Frankfurt Rhein-Main) Projekte entwickelt, die sich mit telemedizinischen Arzt-zu-Arzt-Anwendungen im Bereich der Epilepsieversorgung beschäftigen. $\textbf {Ziel der Arbeit}$ Im Folgenden wird ein Überblick über die aktuell laufenden telemedizinischen Projekte in der Epilepsieversorgung in Deutschland gegeben. $\textbf {Material und Methoden}$ Die Verantwortlichen der einzelnen Projekte stellen ihr Projekt anhand einer vorgegebenen Struktur dar. $\textbf {Ergebnisse und Diskussion}$ In allen Projekten konnte gezeigt werden, dass eine technische Lösung für die telemedizinische Arzt-zu-Arzt Anwendung im Bereich Epileptologie geschaffen werden kann. Die dargestellten Projekte unterscheiden sich zum Teil hinsichtlich des Zieles und der Umsetzung, zum Teil zeigen sich Übereinstimmungen. Perspektivisches Ziel ist es, aus den Erfahrungen der einzelnen Projekte eine gemeinsame Strategie zur Förderung epileptologischer Telemedizin und ihrer Überführung in die Regelversorgung zu entwickeln.$\bf Background$ During the last 10 years several German epilepsy centers (Bochum, Erlangen, Greifswald, Berlin Brandenburg, Frankfurt Rhein-Main) developed telemedicine projects, which offer doc-to-doc applications in the field of epilepsy care. $\bf Objective$ To give an overview of the currently running telemedical projects in epilepsy care in Germany. $\textbf {Material and methods}$ Project leaders present their work using a predefined schematic. $\textbf {Results and discussion}$ All projects achieved technical solutions for the telemedical doc-to-doc application in the field of epileptology. The presented projects partly differ with regards to their goals and implementation, partly they share similarities. All projects aim to use their experience in the individual projects to develop a common strategy for the facilitation of epileptological telemedicine and its transfer into standard care

Validating EEG source imaging using intracranial electrical stimulation

Electrical source imaging is used in presurgical epilepsy evaluation and in cognitive neurosciences to localize neuronal sources of brain potentials recorded on EEG. This study evaluates the spatial accuracy of electrical source imaging for known sources, using electrical stimulation potentials recorded on simultaneous stereo-EEG and 37-electrode scalp EEG, and identifies factors determining the localization error. In 11 patients undergoing simultaneous stereo-EEG and 37-electrode scalp EEG recordings, sequential series of 99–110 biphasic pulses (2 ms pulse width) were applied by bipolar electrical stimulation on adjacent contacts of implanted stereo-EEG electrodes. The scalp EEG correlates of stimulation potentials were recorded with a sampling rate of 30 kHz. Electrical source imaging of averaged stimulation potentials was calculated utilizing a dipole source model of peak stimulation potentials based on individual four-compartment finite element method head models with various skull conductivities (range from 0.0413 to 0.001 S/m). Fitted dipoles with a goodness of fit of $\geq$80% were included in the analysis. The localization error was calculated using the Euclidean distance between the estimated dipoles and the centre point of adjacent stimulating contacts. A total of 3619 stimulation locations, respectively, dipole localizations, were included in the evaluation. Mean localization errors ranged from 10.3 to 26 mm, depending on source depth and selected skull conductivity. The mean localization error increased with an increase in source depth ($\it r$(3617) = [0.19], $\it P$ = 0.000) and decreased with an increase in skull conductivity ($\it r$(3617) = [−0.26], $\it P$ = 0.000). High skull conductivities (0.0413–0.0118 S/m) yielded significantly lower localization errors for all source depths. For superficial sources (40 mm, high skull conductivities of 0.0413 and 0.0206 S/m yielded significantly lower localization errors. In relation to stimulation locations, the majority of estimated dipoles moved outward-forward-downward to inward-forward-downward with a decrease in source depth and an increase in skull conductivity. Multivariate analysis revealed that an increase in source depth, number of skull holes and white matter volume, while a decrease in skull conductivity independently led to higher localization error. This evaluation of electrical source imaging accuracy using artificial patterns with a high signal-to-noise ratio supports its application in presurgical epilepsy evaluation and cognitive neurosciences. In our artificial potential model, optimizing the selected skull conductivity minimized the localization error. Future studies should examine if this accounts for true neural signals

Point-of-care testing using a neuropsychology pocketcard set

Neurocognitive screening instruments usually require printed sheets and additional accessories, and can be unsuitable for low-threshold use during ward rounds or emergency workup, especially in patients with motor impairments. Here, we test the utility of a newly developed neuropsychology pocketcard set for point-of-care testing. For aphasia and neglect assessment, modified versions of the Language Screening Test and the Bells Test were validated on 63 and 60 acute stroke unit patients, respectively, against expert clinical evaluation and the original pen-and-paper Bells Test. The pocketcard aphasia test achieved an excellent area under the curve (AUC) of 0.94 (95% CI: 0.88–1, $\it p$ < 0.001). Using an optimal cut-off of $\geq$2 mistakes, sensitivity was 91% and specificity was 81%. The pocketcard Bells Task, measured against the clinical neglect diagnosis, achieved higher sensitivity (89%) and specificity (88%) than the original paper-based instrument (78% and 75%, respectively). Separately, executive function tests (modified versions of the Trail Making Test [TMT] A and B, custom Stroop color naming task, vigilance 'A' Montreal Cognitive Assessment item) were validated on 44 inpatients with epilepsy against the EpiTrack® test battery. Pocketcard TMT performance was significantly correlated with the original EpiTrack® versions (A: $\it r$ = 0.64, $\it p$ < 0.001; B: $\it r$ = 0.75, $\it p$ < 0.001). AUCs for the custom Stroop task, TMT A and TMT B for discriminating between normal and pathological EpiTrack® scores were acceptable, excellent and outstanding, respectively. Quick point-of-care testing using a pocketcard set is feasible and yields diagnostically valid information

Screening for psychiatric comorbidities and psychotherapeutic assessment in inpatient epilepsy care

$\bf Background:$ Anxiety and depression remain underdiagnosed in routine clinical practice in up to two thirds of epilepsy patients despite significant impact on medical and psychosocial outcome. Barriers to adequate mental health care for epilepsy and/or psychogenic non-epileptic seizures (PNES) include a lack of integrated mental health specialists and standardized procedures. This naturalistic study outlines the procedures and outcome of a recently established psychotherapeutic service. $\bf Methods:$ Routine screening included the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E, cut-off value > 13) and Generalized Anxiety Disorder scale (GAD-7, cut-off value > 5). Positively (above cut-off in at least one questionnaire) screened patients were seen for a standardized interview for mental health disorders and the development of a personalized treatment plan. PNES patients were seen irrespective of their screening score. Resources were provided to support self-help and access to psychotherapy. Patients were contacted 1 month after discharge to evaluate adherence to therapeutic recommendations. $\bf Results:$ 120 patients were screened. Overall, 56 of 77 positively screened patients (77%) were found to have a psychiatric diagnosis through standardized interview. More epilepsy patients with an anxiety disorder had previously been undiagnosed compared to those with a depressive episode (63% vs. 30%); 24 epilepsy patients (62%) with a psychiatric comorbidity and 10 PNES patients (59%) were not receiving any mental health care. At follow-up, 16/17 (94%) epilepsy patients and 7/7 PNES patients without prior psychiatric treatment were adhering to therapeutic recommendations. $\bf Conclusion:$ Integrating mental health specialists and establishing standardized screening and follow-up procedures improve adherence to mental health care recommendations in epilepsy and PNES patients