BACKGROUND: Ultrabrief stimulation in electroconvulsive therapy (ECT) using a 0.25 or 0.30 ms pulse width markedly reduces the charge required to reach the seizure threshold (ST) and cognitive side effects. It is not known whether further reduction of pulse width to 0.15 ms is advantageous. METHODS: Thirty-seven patients were randomized to ST titration at the first session applying right unilateral (RUL) ECT with either a 0.15 or 0.30 ms pulse width and were titrated again in the second session using the alternative pulse width. All subsequent treatments used the pulse width applied in the second titration session, administering RUL ECT, starting at 6xST. The primary outcome was difference between the pulse widths in ST at the two titration sessions. Exploratory analyses examined differences in seizure duration and postictal time to recover orientation (TRO), averaged across all ECT sessions from the third onwards. Other exploratory analyses examined clinical improvement and retrograde amnesia for autobiographical information and other neuropsychological functions following the ECT course. RESULTS: In the first titration session, ST was significantly lower with the 0.15 ms than 0.30 ms pulse width. ST significantly increased when re-titrating with the 0.30 ms pulse width and significantly decreased when re-titrating with a 0.15 ms pulse width. There were no differences between the pulse width groups in clinical improvement, TRO, or neuropsychological measures. CONCLUSIONS: Ultra-ultrabrief stimulation with a 0.15 ms pulse width is more efficient in seizure induction than a 0.30 ms pulse width. Comprehensive studies should determine whether ultra-ultrabrief stimulation replaces ultrabrief stimulation as a default parameter for ECT.

• MeSH
• Adult MeSH
• Electroconvulsive Therapy * methods   adverse effects   MeSH
• Middle Aged MeSH
• Humans MeSH
• Aged MeSH
• Treatment Outcome MeSH
• Seizures therapy   MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Randomized Controlled Trial MeSH
• Comparative Study MeSH

INTRODUCTION: Diagnostic cortical stimulation (CS) in intracranial electroencephalography (iEEG) is an established epilepsy presurgical assessment tool to delineate relevant brain functions and elicit habitual epileptic seizures. Currently, no consensus exists as to whether CS should be routinely performed in pediatric patients. A significant challenge is their limited ability to cooperate during the procedure or to describe non-observable seizure semiology features. Our goal was to identify the spectrum of CS practices in Canada, for both eloquent cortex mapping and seizure stimulation. METHODS: An online survey, answered by all 8 Canadian pediatric epilepsy centers, enquired about implantation, stimulation methods, and use of standardized protocols. A systematic literature review extracted detailed stimulation parameters. RESULTS: Most of the institutions (n = 7/8) reported performing CS during presurgical evaluation. Four institutions indicated they perform stimulation in all implanted patients for the purpose of eloquent cortex mapping and seizure stimulation. The majority of physicians had their individual approach to CS. A largely variable approach to CS, mainly in the choice of stimulation parameters (i.e., train and pulse duration), was observed, with the highest variance concerning the purpose of seizure stimulation. The literature review highlighted an overall small sample size and minimal number of publications. Even though there is a rising trend towards stereotactic iEEG implantation, more data were available on subdural EEGs. CONCLUSION: This study shows individual and sparsely validated approach to CS in pediatric epilepsy. The literature review underscores the urgent need to harmonize pediatric intracranial EEG practices. More multicenter studies are needed to identify safe stimulation thresholds and allow implementation of evidence-based guidelines.

• MeSH
• Child MeSH
• Electroencephalography methods   MeSH
• Electrocorticography methods   MeSH
• Epilepsy surgery   physiopathology   diagnosis   MeSH
• Humans MeSH
• Brain Mapping * methods   MeSH
• Cerebral Cortex physiopathology   MeSH
• Pediatrics methods   MeSH
• Surveys and Questionnaires MeSH
• Seizures * physiopathology   diagnosis   MeSH
• Check Tag
• Child MeSH
• Humans MeSH
• Publication type
• Journal Article MeSH
• Systematic Review MeSH
• Geographicals
• Canada MeSH

Seizures elicited by corneal 6-Hz stimulation are widely acknowledged as a model of temporal lobe seizures. Despite the intensive research in rodents, no studies hint at this model in developing animals. We focused on seven age groups of both male and female rats. Biphasic pulses with 0.3 ms duration and current intensities from 20 to 80 mA were applied transcorneally for 3 s to calculate threshold intensities for individual age groups. Threshold stimulation intensity necessary for elicitation of clonic seizures was highly age- and sex-dependent. The highest threshold was observed in the youngest (15-day-old) group then it decreased to the age of 25 days and increased again up to adulthood. The threshold current tended to be lower in females of all age groups. The incidence of convulsive seizures increased with stimulation intensity up to postnatal day 25 in either sex. In rats of 31 days old and older convulsions occurred irregularly regardless of the stimulation current and sex. For subsequent analysis, the animals were categorized into two groups: juveniles, aged 15 to 25 days, and adolescents/adults, aged 31 days and older. Our statistical analyses revealed an increased risk of convulsions after the stimulation with higher intensities in juvenile but not adolescent/adult rats. Females tended to be more sensitive to the stimulation with lower currents than males. Seizure severity was higher in females 18- to 25-day old compared to males of the same age and the seizure duration increased with stimulation intensities in juvenile but not adolescent/adult animals. The data extend the use of the rat 6 Hz model to immature animals and may be useful as a model of pediatric temporal lobe seizures.

• MeSH
• Electric Stimulation * MeSH
• Rats MeSH
• Disease Models, Animal MeSH
• Cornea physiopathology   pathology   MeSH
• Age Factors MeSH
• Seizures * physiopathology   etiology   MeSH
• Animals MeSH
• Check Tag
• Rats MeSH
• Male MeSH
• Female MeSH
• Animals MeSH
• Publication type
• Journal Article MeSH

Elektrokonvulzívna terapia (ECT) má v psychiatrii svoje stále miesto a nezastupiteľnú úlohu v liečbe závažných psychických porúch. Výskyt vážnejších nežiaducich účinkov je zriedkavý, mortalita ECT je nižšia, v porovnaní s inými lekárskymi zákrokmi realizovanými v celkovej anestéze. V súvislosti s ECT sa popisujú rôzne poruchy kognitívnych funkcií, ktoré predstavujú riziko z hľadiska negatívneho vplyvu na kvalitu života pacienta. Obavy z ich výskytu a údajnej vysokej závažnosti dlhodobo pretrvávajú v laickej verejnosti. Jedná sa o tzv. nesystematický prehľad. Literárne zdroje boli čerpané najmä z databázy PubMed (metaanalýzy, systematické prehľadové práce a klinické štúdie, publikované na danú tématiku v priebehu posledných 10 rokov). Podľa nedávnej a pomerne rozsiahlej metaanalýzy bol výskyt subjektívnych kognitívnych nežiaducich účinkov u pacientov po ECT zaznamenaný v 48 % prípadov. Podľa aktuálne dostupných údajov sú však väčšinou prechodné, krátkodobé a týkajú sa len určitých kognitívnych domén (rýchlosť spracovania informácií, exekutívne funkcie, pozornosť, pracovná a verbálna pamäť, autobiografická pamäť). Napriek tomu porucha autobiografickej pamäti môže pretrvávať v niektorých prípadoch aj viac ako 1 rok s parciálnou ireverzibilitou. Na výskyt kognitívnych nežiaducich účinkov má vplyv viacero modifikovateľných faktorov, ktoré je potrebné poznať a rešpektovať. Podstatným z nich je individualizácia množstva aplikovaného elektrického náboja počas ECT prostredníctvom jeho postupnej titrácie, za účelom nájdenia individuálneho záchvatového prahu. Jednoznačne by mali byť uprednostňované ultrakrátke impulzy (0,3ms) pred dlhšími. Ak to klinický stav umožní, je vhodné použiť unilaterálne umiestnenie elektród (nad nedominantnou hemisférou). Neodporúča sa podávanie viac ako 12 aplikácií v jednej sérii v akútnej fáze liečby (pri bitemporálnom umiestnení elektród). Individuálne faktory pacienta, ku ktorým sa radia vyšší vek, ženské pohlavie, prítomnosť organického poškodenia mozgu a nižší intelekt, predstavujú vyššie riziko rozvoja kognitívnych nežiaducich účinkov po ECT, rovnako aj súbežná liečba lítiom počas ECT. Súčasné národné a medzinárodné odporúčania ponúkajú rôzne psychometrické inštrumenty na monitorovanie kognitívnych nežiaducich účinkov ECT. V niektorých krajinách, napríklad v nemecky hovoriacich regiónoch, ale ani na Slovensku, konkrétne odporúčania neboli vypracované. V dnešnej dobe existujú batérie testov hodnotiace relevantné kognitívne domény, ktoré je možné pri ECT použiť v klinickej praxi, pretože nie sú časovo ani odborne náročné na administráciu. Jedná sa napr. o ECCA test (ElectroConvulsive therapy Cognitive Assessment), prípadne o batériu B4ECT-ReCoDe (Battery for ECT Related Cognitive Deficits). Komplikáciou ich využitia v podmienkach Slovenskej i Českej republiky je, že tam nie sú štandardizované. Alternatívou je použitie jednotlivých testov na spomenuté domény. Významné je najmä hodnotenie dĺžky dezorientácie pacienta po ECT zákrokoch, vyhodnocovanie autobiografickej pamäti, schopnosti verbálneho učenia, exekutívnych funkcií a rýchlosti spracovania informácií a pozornosti, resp. pracovnej pamäti. Hodnotenie výskytu a závažnosti kognitívnych nežiaducich účinkov u pacientov podstupujúcich ECT je v praxi potrebné, zníži riziko rozvoja ich závažnejšieho stupňa, prispeje k optimalizácii liečby, ako aj k zlepšeniu spolupráce pacientov pri tejto terapii.

Electroconvulsive therapy (ECT) has a solid place in psychiatry and an irreplaceable role in the treatment of serious mental disorders. The occurrence of serious side effects is rare, the mortality rate of ECT is lower, compared to other medical interventions performed under general anesthesia. In connection with ECT, various disorders of cognitive functions are described, which pose a risk in terms of a negative impact on the patient ́s quality of life. Concerns about their occurrence and alleged high severity persist for a long time in the public. This is the so-called unsystematic review. Literary sources were mainly drawn from the PubMed database (meta-analyses, systematic review works and clinical studies published on the given topic during the last 10 years). According to a recent and fairly extensive meta-analysis, the occurrence of subjective cognitive side effects in patients after ECT was recorded in 48% of cases. However, according to the currently available data, they are mostly transitory, short-term and affect only certain cognitive domains (information processing speed, executive functions, attention, working and verbal memory, autobiographical memory). Nevertheless, the autobiographical memory disorder can persist in some cases for more than 1 year with partial irreversibility. The occurrence of cognitive side effects is influenced by several modifiable factors that need to be known and respected. An essential one is the individualization of the amount of applied electric charge during ECT through its gradual titration, in order to find the individual seizure threshold. Ultrabrief pulses (0.3ms) should clearly be preferred over longer ones. If the clinical condition allows it, it is advisable to use unilateral electrode placement (over the non-dominant hemisphere). It is not recommended to administer more than 12 applications in one series in the acute phase of treatment (with bitemporal placement of electrodes). Individual patient factors such as older age, female gender, presence of organic brain damage, and lower intellect pose a higher risk of developing cognitive adverse effects after ECT. So does concurrent lithium treatment during ECT. Current national and international guidelines offer various psychometric instruments to monitor the cognitive side effects of ECT. In some countries, for example in German-speaking regions, but also in Slovakia, specific recommendations have not been developed. Nowadays, there are batteries of tests evaluating relevant cognitive domains that can be used in clinical practice during ECT, because they are neither time nor expertly hard to administer. It is, for example, the ECCA test (ElectroConvulsive therapy Cognitive Assessment), or the B4ECT-ReCoDe battery (Battery for ECT Related Cognitive Deficits). The complication of their use in the conditions of Slovakia and the Czech Republic is that they are not standardized there. An alternative is to use individual tests for the mentioned domains. It is particularly important to assess the length of the patient ́s disorientation after ECT procedures, the evaluation of autobiographical memory, verbal learning ability, executive functions and information processing speed and attention, or working memory. Assessment of the occurrence and severity of cognitive side effects in patients undergoing ECT is necessary in practice, it will reduce the risk of developing their more severe degree, contribute to the optimization of treatment, as well as to the improvement of patient cooperation in this therapy.

• MeSH
• Electric Stimulation methods   adverse effects   MeSH
• Electroconvulsive Therapy * methods   adverse effects   MeSH
• Memory, Episodic MeSH
• Cognition Disorders * etiology   pathology   MeSH
• Humans MeSH
• Meta-Analysis as Topic MeSH
• Check Tag
• Humans MeSH

Seizures beget seizures is a longstanding theory that proposed that seizure activity can impact the structural and functional properties of the brain circuits in ways that contribute to epilepsy progression and the future occurrence of seizures. Originally proposed by Gowers, this theory continues to be quoted in the pathophysiology of epilepsy. We critically review the existing data and observations on the consequences of recurrent seizures on brain networks and highlight a range of factors that speak for and against the theory. The existing literature demonstrates clearly that ictal activity, especially if recurrent, induces molecular, structural, and functional changes including cell loss, connectivity reorganization, changes in neuronal behavior, and metabolic alterations. These changes have the potential to modify the seizure threshold, contribute to disease progression, and recruit wider areas of the epileptic network into epileptic activity. Repeated seizure activity may, thus, act as a pathological positive-feedback mechanism that increases seizure likelihood. On the other hand, the time course of self-limited epilepsies and the presence of seizure remission in two thirds of epilepsy cases and various chronic epilepsy models oppose the theory. Experimental work showed that seizures could induce neural changes that increase the seizure threshold and decrease the risk of a subsequent seizure. Due to the complex nature of epilepsies, it is wrong to consider only seizures as the key factor responsible for disease progression. Epilepsy worsening can be attributed to the various forms of interictal epileptiform activity or underlying disease mechanisms. Although seizure activity can negatively impact brain structure and function, the "seizures beget seizures" theory should not be used dogmatically but with extreme caution.

• MeSH
• Epilepsy * MeSH
• Humans MeSH
• Brain MeSH
• Neurons MeSH
• Disease Progression MeSH
• Seizures * MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH

OBJECTIVE: High-frequency oscillations are considered among the most promising interictal biomarkers of the epileptogenic zone in patients suffering from pharmacoresistant focal epilepsy. However, there is no clear definition of pathological high-frequency oscillations, and the existing detectors vary in methodology, performance, and computational costs. This study proposes relative entropy as an easy-to-use novel interictal biomarker of the epileptic tissue. METHODS: We evaluated relative entropy and high-frequency oscillation biomarkers on intracranial electroencephalographic data from 39 patients with seizure-free postoperative outcome (Engel Ia) from three institutions. We tested their capability to localize the epileptogenic zone, defined as resected contacts located in the seizure onset zone. The performance was compared using areas under the receiver operating curves (AUROCs) and precision-recall curves. Then we tested whether a universal threshold can be used to delineate the epileptogenic zone across patients from different institutions. RESULTS: Relative entropy in the ripple band (80-250 Hz) achieved an average AUROC of .85. The normalized high-frequency oscillation rate in the ripple band showed an identical AUROC of .85. In contrast to high-frequency oscillations, relative entropy did not require any patient-level normalization and was easy and fast to calculate due to its clear and straightforward definition. One threshold could be set across different patients and institutions, because relative entropy is independent of signal amplitude and sampling frequency. SIGNIFICANCE: Although both relative entropy and high-frequency oscillations have a similar performance, relative entropy has significant advantages such as straightforward definition, computational speed, and universal interpatient threshold, making it an easy-to-use promising biomarker of the epileptogenic zone.

• MeSH
• Biomarkers MeSH
• Electroencephalography * methods   MeSH
• Electrocorticography methods   MeSH
• Entropy MeSH
• Epilepsy * diagnosis   surgery   MeSH
• Humans MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Research Support, N.I.H., Extramural MeSH

OBJECTIVES: High counts of averaged interictal epileptiform discharges (IEDs) are key components of accurate interictal electric source imaging (ESI) in patients with focal epilepsy. Automated detections may be time-efficient, but they need to identify the correct IED types. Thus we compared semiautomated and automated detection of IED types in long-term video-EEG (electroencephalography) monitoring (LTM) using an extended scalp EEG array and short-term high-density EEG (hdEEG) with visual detection of IED types and the seizure-onset zone (SOZ). METHODS: We prospectively recruited consecutive patients from four epilepsy centers who underwent both LTM with 40-electrode scalp EEG and short-term hdEEG with 256 electrodes. Only patients with a single circumscribed SOZ in LTM were included. In LTM and hdEEG, IED types were identified visually, semiautomatically and automatically. Concordances of semiautomated and automated detections in LTM and hdEEG, as well as visual detections in hdEEG, were compared against visually detected IED types and the SOZ in LTM. RESULTS: Fifty-two of 62 patients with LTM and hdEEG were included. The most frequent IED types per patient, detected semiautomatically and automatically in LTM and visually in hdEEG, were significantly concordant with the most frequently visually identified IED type in LTM and the SOZ. Semiautomated and automated detections of IED types in hdEEG were significantly concordant with visually identified IED types in LTM, only when IED types with more than 50 detected single IEDs were selected. The threshold of 50 detected IED in hdEEG was reached in half of the patients. For all IED types per patient, agreement between visual and semiautomated detections in LTM was high. SIGNIFICANCE: Semiautomated and automated detections of IED types in LTM show significant agreement with visually detected IED types and the SOZ. In short-term hdEEG, semiautomated detections of IED types are concordant with visually detected IED types and the SOZ in LTM if high IED counts were detected.

• MeSH
• Electroencephalography methods   MeSH
• Epilepsies, Partial * diagnosis   MeSH
• Humans MeSH
• Magnetic Resonance Imaging methods   MeSH
• Prospective Studies MeSH
• Scalp * MeSH
• Seizures MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH

INTRODUCTION: A high seizure threshold (ST) is an impeding factor in certain patients, potentially preventing a successful electroconvulsive therapy (ECT) treatment. Several pharmacological and non-pharmacological methods have been put forward to augment ECT in such patients, however, to this date, only a handful of case reports existed about the potential role of repetitive transcranial magnetic stimulation (rTMS), as an augmentation method. OBJECTIVES: and Methods: In this randomized, double-blinded, sham controlled study, we set out to test the hypothesis of whether the application of high frequency transcranial magnetic stimulation (HF rTMS) lowers the seizure threshold for electroconvulsive therapy and whether it has an effect on other aspects of ECT treatment, such as seizure duration (SD), efficacy and safety. RESULTS: 46 patients treated for a major depressive episode, indicated for ECT, were recruited to this study. A significantly lower seizure threshold was observed in the experimental group during ECT titration, on average a decrease by 34.55%, from 34.23 mC to 22.4 mC, p < 0.001 (Wilcox test). We had not observed a significant effect of TMS stimulation before ECT on seizure duration or clinical outcome. Another potentially important observation of this study is that 4 patients in the experimental group developed transient symptoms of hypomania/mania, all of which were stabilized after the combined stimulation protocol was halted spontaneously within a week, without the need to administer mood stabilizers. CONCLUSION: It is likely that HF rTMS stimulation prior to ECT is a novel and simple way of reducing the ST, which is useful in certain groups of patients undergoing this important treatment modality.

• MeSH
• Anticonvulsants therapeutic use   MeSH
• Depressive Disorder, Major diagnosis   physiopathology   therapy   MeSH
• Adult MeSH
• Double-Blind Method MeSH
• Electroconvulsive Therapy methods   MeSH
• Middle Aged MeSH
• Humans MeSH
• Follow-Up Studies MeSH
• Statistics, Nonparametric MeSH
• Transcranial Magnetic Stimulation methods   MeSH
• Seizures diagnosis   etiology   physiopathology   MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Randomized Controlled Trial MeSH

This study aims to investigate whether intranetwork dynamic functional connectivity and causal interactions of the salience network is altered in the interictal term of migraine. Thirty-two healthy controls, 37 migraineurs without aura, and 20 migraineurs with aura were recruited. Participants underwent a T1-weighted scan and resting-state fMRI protocol inside a 1.5T MR scanner. We obtained average spatial maps of resting-state networks using group independent component analysis, which yielded subject-specific time series through a dual regression approach. Salience network regions of interest (bilateral insulae and prefrontal cortices, dorsal anterior cingulate cortex) were obtained from the group average map through cluster-based thresholding. To describe intranetwork connectivity, average and dynamic conditional correlation was calculated. Causal interactions between the default-mode, dorsal attention, and salience network were characterised by spectral Granger's causality. Time-averaged correlation was lower between the right insula and prefrontal cortex in migraine without aura vs with aura and healthy controls (P < 0.038, P < 0.037). Variance of dynamic conditional correlation was higher in migraine with aura vs healthy controls and migraine with aura vs without aura between the right insula and dorsal anterior cingulate cortex (P < 0.011, P < 0.026), and in migraine with aura vs healthy controls between the dorsal anterior cingulate and left prefrontal cortex (P < 0.021). Causality was weaker in the <0.05 Hz frequency range between the salience and dorsal attention networks in migraine with aura (P < 0.032). Overall, migraineurs with aura exhibit more fluctuating connections in the salience network, which also affect network interactions, and could be connected to altered cortical excitability and increased sensory gain.

• MeSH
• Epilepsy MeSH
• Humans MeSH
• Magnetic Resonance Imaging MeSH
• Brain Mapping MeSH
• Migraine with Aura * MeSH
• Nerve Net diagnostic imaging   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH

OBJECTIVE: This paper introduces a fully automated, subject-specific deep-learning convolutional neural network (CNN) system for forecasting seizures using ambulatory intracranial EEG (iEEG). The system was tested on a hand-held device (Mayo Epilepsy Assist Device) in a pseudo-prospective mode using iEEG from four canines with naturally occurring epilepsy. APPROACH: The system was trained and tested on 75 seizures collected over 1608 d utilizing a genetic algorithm to optimize forecasting hyper-parameters (prediction horizon (PH), median filter window length, and probability threshold) for each subject-specific seizure forecasting model. The trained CNN models were deployed on a hand-held tablet computer and tested on testing iEEG datasets from four canines. The results from the iEEG testing datasets were compared with Monte Carlo simulations using a Poisson random predictor with equal time in warning to evaluate seizure forecasting performance. MAIN RESULTS: The results show the CNN models forecasted seizures at rates significantly above chance in all four dogs (p   <  0.01, with mean 0.79 sensitivity and 18% time in warning). The deep learning method presented here surpassed the performance of previously reported methods using computationally expensive features with standard machine learning methods like logistic regression and support vector machine classifiers. SIGNIFICANCE: Our findings principally support the feasibility of deploying trained CNN models on a hand-held computational device (Mayo Epilepsy Assist Device) that analyzes streaming iEEG data for real-time seizure forecasting.

• MeSH
• Deep Learning * MeSH
• Electrocorticography instrumentation   methods   MeSH
• Epilepsy diagnosis   physiopathology   MeSH
• Electrodes, Implanted * MeSH
• Forecasting MeSH
• Dogs MeSH
• Seizures diagnosis   physiopathology   MeSH
• Animals MeSH
• Check Tag
• Dogs MeSH
• Animals MeSH
• Publication type
• Journal Article MeSH