American Clinical Neurophysiology Society Research Articles

Cyclic Alternating EEG Patterns: From Sleep to Encephalopathy.

In the 2021 version of the Standardized Critical Care EEG Terminology, the American Clinical Neurophysiology Society introduced new definitions, including for the cyclic alternating pattern of encephalopathy (CAPE). CAPE refers to changes in background EEG activity, with two patterns alternating spontaneously in a regular manner. CAPE shares remarkable similarities with the cyclic alternating pattern, a natural EEG phenomenon occurring in normal non-rapid eye movement sleep, considered the main electrophysiological biomarker of sleep instability. This review explores similarities and differences between cyclic alternating pattern and CAPE and, leveraging the existing expertise on cyclic alternating pattern, aims to extend knowledge on CAPE. A standardized assessment of CAPE features is key to ascertain its prevalence and clinical significance among critically ill patients and to encompass the impact of confounding factors such as anesthetic and sedative agents. Although the preservation of non-rapid eye movement sleep-related elements has a well-known prognostic value in the critical care setting, the clinical importance of cyclic oscillating patterns and the prognostic significance of CAPE remain to be elucidated.

Differentiating rhythmic high-amplitude delta with superimposed (poly) spikes from extreme delta brushes: limitations of standardized nomenclature and implications for patient management.

Following the standardized nomenclature proposed by the American Clinical Neurophysiology Society (ACNS), rhythmic high-amplitude delta activity with superimposed spikes (RHADS) can be reported as an extreme delta brush (EDB). The clinical implications of similar electrographic patterns being reported as RHADS versus EDB are important to highlight. We aim to review the electrographic characteristics of RHADS, evaluate whether RHADS is seen in other neurological disorders, and identify the similar and unique characteristics between RHADS and EDB to ultimately determine the most accurate way to differentiate and report these patterns. We believe that the differentiation of RHADS and EDB is important as there is a vast difference in the diagnostic approach and the medical management of associated underlying etiologies. We conducted an extensive search on MEDLINE and Pubmed utilizing various combinations of keywords. Searching for "gamma polymerase and EEG", or "RHADS" or "Alpers syndrome and EEG" or "EEG" AND "Alpers-Huttenlocher syndrome". Three articles were found to be focused on the description of "RHADS" pattern in Alpers Syndrome. No publication to date were found when searching for the terms "EDB" AND "children", AND "infant" AND "adolescent" excluding "encephalitis" and "neonate". Although RHADS and EDB appear as similar EEG patterns, meticulous analysis can differentiate them. RHADS is not exclusive to patients with Alpers-Huttenlocher syndrome and may manifest in regions beyond the posterior head region. Reactivity to eye-opening and response to anesthesia can be two other elements that help in the differentiation of these patterns. RHADS is not exclusive to patients with AHS and may manifest in regions beyond the posterior head region. Reactivity to eye-opening and response to anesthesia are features that help in the differentiation of these patterns.

Ictal-Interictal Continuum in the Pediatric Intensive Care Unit.

The ictal-interictal continuum (IIC) consists of several electroencephalogram (EEG) patterns that are common in critically ill adults. Studies focused on the IIC are limited in critically ill children and have focused primarily on associations with electrographic seizures (ESs). We report the incidence of the IIC in the pediatric intensive care unit (PICU). We then compare IIC patterns to rhythmic and periodic patterns (RPP) not meeting IIC criteria looking for associations with acute cerebral abnormalities, ES, and in-hospital mortality. This was a retrospective review of prospectively collected data for patients admitted to the PICU at Children's National Hospital from July 2021 to January 2023 with continuous EEG. We excluded patients with known epilepsy and cerebral injury prior to presentation. All patients were screened for RPP. The American Clinical Neurophysiology Society standardized Critical Care EEG terminology for the IIC was applied to each RPP. Associations between IIC and RPP not meeting IIC criteria, with clinical and EEG variables, were calculated using odds ratios (ORs). Of 201 patients, 21% (42/201) had RPP and 12% (24/201) met IIC criteria. Among patients with an IIC pattern, the median age was 3.4years (interquartile range (IQR) 0.6-12years). Sixty-seven percent (16/24) of patients met a single IIC criterion, whereas the remainder met two criteria. ESs were identified in 83% (20/24) of patients and cerebral injury was identified in 96% (23/24) of patients with IIC patterns. When comparing patients with IIC patterns with those with RPP not qualifying as an IIC pattern, both patterns were associated with acute cerebral abnormalities (IIC OR 26 [95% confidence interval {CI} 3.4-197], p = 0.0016 vs. RPP OR 3.5 [95% CI 1.1-11], p = 0.03), however, only the IIC was associated with ES (OR 121 [95% CI 33-451], p < 0.0001) versus RPP (OR 1.3 [0.4-5], p = 0.7). Rhythmic and periodic patterns and subsequently the IIC are commonly seen in the PICU and carry a high association with cerebral injury. Additionally, the IIC, seen in more than 10% of critically ill children, is associated with ES. The independent impact of RPP and IIC patterns on secondary brain injury and need for treatment of these patterns independent of ES requires further study.

Survey on Power and Area efficient FIR Filter Architecture in Digital Encephalography System

In the process of Electroencephalogram (EEG) acquisition, the electrical signals from the brain are contaminated by numerous noise sources and artifacts. American Clinical Neurophysiology Society recommends digital filtering of acquired EEG signals with an upper cut-off frequency of 70 Hz before display in digital encephalography systems. We propose a linear symmetrical FIR filter architecture for filtering EEG signals using approximate computation techniques. Approximate computation techniques result in lower hardware resources and lower power consumption with some compromise in quality. Software tools used for this study include MATLAB (and its FDA tool) and Xilinx ISE 14.7. The chosen target platform is the Spartan-3e starter FPGA board. We propose the architecture for an Approximate Dadda Tree Multiplier. The proposed approximate multiplier consumes 25% lesser slices and 35.18% lower dynamic power than state-of-the-art approximate multipliers. The proposed FIR filter consumes 19.77% lesser LUTs and 34.97% lower power than state-of-the-art symmetric FIR filter architectures.

The Management of Intraoperative Spinal Cord Injury - A Scoping Review.

Scoping Review. To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae.

Response to Letters to the Editor by Gregory J, Rice K, McCarthy K, et al. 2023 Regarding: "Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET-The Neurodiagnostic Society".

Response to Letters to the Editor by Gregory J, Rice K, McCarthy K, et al. 2023 Regarding: "Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET-The Neurodiagnostic Society".

Letter to the Editor Regarding: "Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET-The Neurodiagnostic Society".

Letter to the Editor Regarding: "Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET-The Neurodiagnostic Society".

Utility of EEG in neurological emergencies and critical care

EEG is useful for evaluation of pathophysiology and prognostication of neurocritically ill patients, as it provides non-invasive, real-time monitoring of cerebral function. There have been recently a lot of advances in research on critical care EEG according to the American Clinical Neurophysiology Society's Standardized Critical Care EEG Terminology. Based on the latest knowledge, this review discusses clinical utilization of EEG in neurocritically ill patients, including critical care continuous EEG monitoring, and key points of interpretation of critical care EEG, classifying main purposes into three points: detection of electrographic and electroclinical seizures, consideration of special encephalopathies, and evaluation and prognostication of cerebral function. Neurologists should have fundamental ability to read and interpret critical care EEG and support treating physicians in terms of therapeutic strategy.

Neuroimaging correlation with EEG in status epilepticus

PurposeThis study was to correlate EEG patterns with peri-ictal perfusion CT abnormality (PCA) or peri-ictal MR abnormality (PMA) in patients with status epilepticus (SE). MethodsThis is a retrospective study done with SE patients from January 2016 to December 2021. We defined the PCA as single or multi-territorial cortical and/or thalamic hyper-perfusion. The PMA was defined as increased signal intensity in multiple brain regions including the cortex and subcortical regions. EEG patterns were categorized into electrographic seizure (ESz)/electroclinical seizure (ECSz), ictal-interictal continuum (IIC), and lateralized periodic discharges (LPDs) per the American Clinical Neurophysiology Society's guideline. We analyzed the association between the patterns of EEG and the presence of PCA or PMA. ResultsAmong 73 patients, 26% (19/73) showed PCA and 25% (18/73) demonstrated PMA. The patterns of EEG were as follows; ESz/ECSz in 25% (18/73), IIC in 34% (25/73), and LPD in 12% (9/73). There was a significant correlation between the patterns of EEG and the presence of PMA, but not PCA. 48% (12/25) had both PMA and PCA whereas 52% (13/25) showed either PMA (6/25) or PCA (7/25). ConclusionAlthough PCA did not reveal an electro-radiographical correlation, PMA was strongly linked to ESz, ECSz, IIC, and LPD.

Periodic discharges plus fast activity on EEG predict worse outcomes in post-stroke epilepsy.

Post-seizure functional decline is a concern in post-stroke epilepsy (PSE). However, data on electroencephalogram (EEG) markers associated with functional decline are scarce. Thus, we investigated whether periodic discharges (PDs) and their specific characteristics are associated with functional decline in patients with PSE. In this observational study, patients admitted with seizures of PSE and who had scalp EEGs were included. The association between the presence or absence of PDs and post-seizure short-term functional decline lasting 7 days after admission was investigated. In patients with PD, EEG markers were explored for risk stratification of short-term functional decline, according to the American Clinical Neurophysiology Society's Standardized Critical Care EEG Terminology. The association between EEG markers and imaging findings and long-term functional decline at discharge and 6 months after discharge, defined as an increase in the modified Rankin Scale score compared with the baseline, was evaluated. In this study, 307 patients with PSE (median age, 75; range, 35-97 years; 64% males; hemorrhagic stroke, 47%) were enrolled. Compared with 247 patients without PDs, 60 patients with PDs were more likely to have short-term functional decline (12 (20%) vs. 8 (3.2%), p < 0.001), with an adjusted odds ratio (OR) of 4.26 (95% confidence interval (CI), 1.44-12.6; p = 0.009). Patients with superimposed fast-activity PDs (PDs+F) had significantly more localized (rather than widespread) lesions (87% vs. 58%, p = 0.003), prolonged hyperperfusion (100% vs. 62%, p = 0.023), and a significantly higher risk of short-term functional decline than those with PDs without fast activity (adjusted OR, 22.0; 95% CI, 1.87-259.4; p = 0.014). Six months after discharge, PDs+F were significantly associated with long-term functional decline (adjusted OR, 4.21; 95% CI, 1.27-13.88; p = 0.018). In PSE, PDs+F are associated with sustained neuronal excitation and hyperperfusion, which may be a predictor of post-seizure short- and long-term functional decline.

Response to a Letter to the Editor by Gregory et al. Regarding: “Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET – The Neurodiagnostic Society”

Response to a Letter to the Editor by Gregory et al. Regarding: “Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET – The Neurodiagnostic Society”

Diagnosing nonconvulsive status epilepticus: Defining electroencephalographic and clinical response to diagnostic intravenous antiseizure medication trials.

The Salzburg criteria for nonconvulsive status epilepticus (NCSE) and the American Clinical Neurophysiology Society (ACNS) Standardized Critical Care EEG Terminology 2021 include a diagnostic trial with intravenous (IV) antiseizure medications (ASMs) to assess electroencephalographic (EEG) and clinical response as a diagnostic criterion for definite NCSE and possible NCSE. However, how to perform this diagnostic test and assessing the EEG and clinical responses have not been operationally defined. We performed a Delphi process involving six experts to standardize the diagnostic administration of IV ASM and propose operational criteria for EEG and clinical response. Either benzodiazepines (BZDs) or non-BZD ASMs can be used as first choice for a diagnostic IV ASM trial. However, non-BZDs should be considered in patients who already have impaired alertness or are at risk of respiratory depression. Levetiracetam, valproate, lacosamide, brivaracetam, or (if the only feasible drug) fosphenytoin or phenobarbital were deemed appropriate for a diagnostic IV trial. The starting dose should be approximately two thirds to three quarters of the full loading dose recommended for treatment of status epilepticus, with an additional smaller dose if needed. ASMs should be administered during EEG recording under supervision. A monitoring time of at least 15 min is recommended. If there is no response, a second trial with another non-BDZ or BDZs may be considered. A positive EEG response is defined as the resolution of the ictal-interictal continuum pattern for at least three times the longest previously observed spontaneous interval of resolution (if any), but minimum of one continuous minute. For a clinical response, physicians should use a standardized examination before and after IV ASM administration. We suggest a definite time-locked improvement in a focal deficit or at least one-step improvement on a new dedicated one-domain 10-level NCSE response scale. The proposed standardized approach of a diagnostic IV ASM trial further refines the ACNS and Salzburg diagnostic criteria for NCSE.

Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET The Neurodiagnostic Society.

The Guidelines for Qualifications of Neurodiagnostic Personnel (QNP) document has been created through the collaboration of the American Clinical Neurophysiology Society (ACNS), the American Society of Neurophysiological Monitoring (ASNM), the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), and ASET The Neurodiagnostic Society (ASET). The quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level. These societies recognize that neurodiagnostics is a large field with practitioners who have entered the field through a variety of training paths. This document suggests job titles, associated job responsibilities, and the recommended levels of education, certification, experience, and ongoing education appropriate for each job. This is important because of the growth and development of standardized training programs, board certifications, and continuing education in recent years. This document matches training, education, and credentials to the various tasks required for performing and interpreting neurodiagnostic procedures. This document does not intend to restrict the practice of those already working in neurodiagnostics. It represents recommendations of these societies with the understanding that federal, state, and local regulations, as well as individual hospital bylaws, supersede these recommendations. Because neurodiagnostics is a growing and dynamic field, the authors fully intend this document to change over time.

Characterizing EEG and Serum Biomarker Trends in Immune Effector Cell-Associated Neurotoxicity: A Case Series (P10-1.001)

<h3>Objective:</h3> To characterize electroencephalographic (EEG) trends over time in immune effector cell-associated neurotoxicity syndrome (ICANS) and identify correlations between neuron-derived serum biomarkers of inflammation, neurotoxicity grade, and EEG findings. <h3>Background:</h3> Chimeric antigen receptor T-cell therapy (CAR-T) can be effective for refractory hematologic malignancies, but may be complicated by ICANS. Previous studies link higher peak neurotoxicity grades with EEG background abnormalities and higher incidences of rhythmic and periodic patterns (RPPs). <h3>Design/Methods:</h3> We performed a retrospective analysis of CAR-T patients who were enrolled into an IRB-approved prospective, longitudinal observational study. Data including demographics, ICE scores, and neurologic symptoms were prospectively entered. Serum biomarkers including Ang-1, Ang-2, IL-6, UCH-L1, and S100b were drawn prior to CAR-T and at defined time points thereafter. EEG data was reviewed, with encephalopathy grade defined by American Clinical Neurophysiology Society (ACNS) criteria. <h3>Results:</h3> Forty-five patients were included in the study. Ten patients (22%) developed ICANS. EEG data was available for five (11%) patients, with a median of 35 hours recorded per patient. Zero patients had confirmed electrographic seizures. Median ICE score prior to EEG was 1. Backgrounds were mildly or moderately encephalopathic, with improving organization and faster frequencies over time. GPDs or LPDs of 0.5–2Hz were rare to abundant and gradually improved with time. Focal slowing and sharp waves were common. S100b consistently increased above (average 45%) and Ang-2 decreased below (average 53%) baseline at the time of becoming symptomatic for two patients (drawn within 48 hours before/after EEG was obtained), whereas Ang-1, IL-6, and UCH-L1 had more variable changes. <h3>Conclusions:</h3> Patients with ICANS who underwent EEGs had up to moderate electrographic (and severe clinical) encephalopathy and RPPs that spontaneously improved with time. Higher encephalopathy grade occurred in those with greater S100b increases. Our observations will need to be confirmed in an independent population with serial samples and EEG data on all patients. <b>Disclosure:</b> Dr. Nguyen has nothing to disclose. Lila Renteria has nothing to disclose. Dr. Motika has nothing to disclose. Dr. Hinson has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Biogen. Dr. Hinson has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for UCSF. Dr. Hinson has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Heart Association.

Development of a structured process for the Spanish translation of the 2021 ACNS standardized critical care EEG terminology (P4-8.010)

<h3>Objective:</h3> To develop a Spanish translation of the 2021 critical care EEG terminology through a structured consensus of an interdisciplinary group with representation from Latin America and Spain. <h3>Background:</h3> Aiming for a common language for the classification of electroencephalogram (EEG) findings in critical care (ICU), the American Clinical Neurophysiology Society (ACNS) published the ICU-EEG terminology in 2013, which was updated in 2021. Since this nomenclature has not been published in Spanish, the potential use of the ICU-EEG terminology can be variable when translated into daily practice in Spanish-speaking countries. <h3>Design/Methods:</h3> The initial translation of the terminology was done in parallel by three subgroups of Spanish-speaking neurophysiologists and neurointensivists representing different regions of Latin America and Spain. Each subgroup worked iteratively on one section of the terminology. Scheduled meetings were carried out with the entire team to discuss translation differences and alternatives, which were recorded for discussion in future planned consensus groups. We have recruited 25 participants from Latin America and Spain to explore their impressions on the applicability, implementation, and regional differences of the translation in different Spanish-speaking countries. Using qualitative methodology, the consensus groups will follow nominal group technique methods. <h3>Results:</h3> The process, common discussion points, and consensus agreements and disagreements of the different terms chosen in the translation will be presented. <h3>Conclusions:</h3> The Spanish language is diverse, and the terms used to describe electroencephalographic findings vary in different countries. It is essential to consider these variations when translating guidelines into other languages. Translations need to be structured, iterative, and consensus-based with representations of different countries with the same language to encourage widespread use and a more homogeneous communication, which can in turn facilitate and encourage future research. <b>Disclosure:</b> Dr. Bruzzone has nothing to disclose. Dr. Rubinos has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Qualtrics Inc. Dr. Rubinos has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for American Epilepsy Society . The institution of Dr. Rubinos has received research support from University of North Carolina . Dr. Lowden has nothing to disclose. Dr. Appendino has nothing to disclose. Dr. Vidaurre has nothing to disclose. Daniel San Juan-Orta has nothing to disclose. Dr. Garcia Losarcos has nothing to disclose. Dr. Villamar has a non-compensated relationship as a Member of Editorial Board with Neurology: Clinical Practice that is relevant to AAN interests or activities. Dr. Villamar has a non-compensated relationship as a Member of Editorial Board with The Neurohospitalist that is relevant to AAN interests or activities. Dr. Burneo has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Elsevier, Clinical Neurology and Neurosurgery Journal. Dr. Burneo has received research support from The Jack Cowin Endowed Chair in Epilepsy Research. Dr. Burneo has received publishing royalties from a publication relating to health care. Dr. Mayor has nothing to disclose. Dr. Rodriguez-Ruiz has received personal compensation in the range of $0-$499 for serving as a Consultant for Atheneum. Dr. Rodriguez-Ruiz has stock in Lourbeth LLC. Dr. Gutierrez has nothing to disclose. Dr. Fernandez has nothing to disclose.

Outcomes of Surgical Resection and VNS in Patients with Medically Refractory Epilepsy and GAD65 Antibody Positivity (S40.004)

<h3>Objective:</h3> To determine effectiveness of vagus nerve stimulator (VNS) and surgical resection in patients with drug-resistant epilepsy associated with glutamic acid decarboxylase 65 (GAD65) antibodies. <h3>Background:</h3> Epilepsy associated with high-titer GAD65 antibodies is often refractory to immunotherapies and antiseizure medications (ASMs), underscoring the need for alternate treatment strategies. <h3>Design/Methods:</h3> We retrospectively identified Mayo Clinic Rochester patients (January 2003 – April 2022) with drug-resistant epilepsy and high serum GAD65-antibody titers (&gt;20 nnmol/L) who underwent surgical resection and/or VNS implantation. A “favorable” surgical outcome was defined as Engel I-II, and a responder to VNS was defined as a &gt;50% reduction in seizure frequency from baseline. <h3>Results:</h3> We identified 15 patients (13 females, 86.7%) who underwent surgical resection (n=7), VNS implantation (n=6), and both (n=2). Patients had failed a median of 5.5 anti-seizure medications. Twelve patients had GAD65 tested in the CSF, all were positive (median titer 3.8). Of the nine patients who underwent surgical intervention (all involving the temporal region), three (33.3%) had a favorable outcome, which was sustained for at least 3.5 years in one, 10 years in another, and the third was lost to follow-up after 1 year. Pathology was available in four patients, only one had evidence of inflammation. Of the 8 patients who underwent VNS implantation, 3 (37.5%) were initially considered a responder, but this was not sustained in two of the three. No clinical factors were statistically associated with favorable surgical or VNS outcomes. <h3>Conclusions:</h3> Temporal surgical resection and VNS are not highly effective in drug-resistant autoimmune-associated epilepsy related to high-titer GAD65 antibodies. Additional therapies are greatly needed for this challenging clinical scenario. <b>Disclosure:</b> Dr. Zhao-Fleming has nothing to disclose. Dr. Britton has received personal compensation in the range of $0-$499 for serving as a Online course with American Clinical Neurophysiology Society. The institution of Dr. Dubey has received personal compensation in the range of $500-$4,999 for serving as a Consultant for UCB. The institution of Dr. Dubey has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Astellas. The institution of Dr. Dubey has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Argenx. Dr. Dubey has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for AGRIMS. Dr. Dubey has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Advances in Neurology . Dr. Dubey has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Moffit Cancer Center . Dr. Dubey has received research support from Department of Defense . Dr. Dubey has received intellectual property interests from a discovery or technology relating to health care. Dr. Dubey has received intellectual property interests from a discovery or technology relating to health care. Dr. Dubey has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Smith has received research support from CURE Epilepsy.

Seizure Control in Women with Epilepsy Undergoing Assisted Reproductive Technology (P14-1.011)

<h3>Objective:</h3> The objective of this study was to determine the effect of assisted reproductive technology on seizure control in women with epilepsy. <h3>Background:</h3> Information available about seizure control in women with epilepsy undergoing assisted reproductive technology is sparse, limited to only a few case reports. Extrapolations are often made from situations that similarly heighten the oestrogen-progesterone ratio. <h3>Design/Methods:</h3> From a database of 3858 women who underwent in vitro fertilization (IVF) or frozen embryo transfer (FET) from January 1992–May 2021, 12 women with epilepsy were identified. Data was obtained through retrospective chart review. <h3>Results:</h3> From the 12 women identified, the median age of epilepsy onset was 20 years of age (range 25 – 42) with 6 (50%) having epilepsy onset in childhood. There were 26 embryo transfers, resulting in 14 pregnancies and 8 live births. Nine women (75%) were seizure free for &gt;2 years prior to infertility treatment. Seven women (58%) were on anti-seizure medications (ASMs) throughout fertility treatment and pregnancy with only one on polytherapy. Levels of ASMs were followed and adjusted in 3 of the 7 (43%). Eleven women (all with controlled epilepsy or epilepsy in remission) remained seizure free throughout fertility treatment. One woman, who had drug-resistant epilepsy, continued to have seizures throughout infertility treatment and pregnancy without an exacerbation of seizure frequency and with close monitoring and adjustment of ASMs. <h3>Conclusions:</h3> There was no seizure worsening in this cohort of 12 women with epilepsy undergoing assisted reproductive technology. <b>Disclosure:</b> Dr. Abdulrazaq has nothing to disclose. Dr. Ainsworth has nothing to disclose. Dr. Britton has received personal compensation in the range of $0-$499 for serving as a Online course with American Clinical Neurophysiology Society. Dr. Shenoy has nothing to disclose. Dr. Babayev has nothing to disclose. Dr. Cascino has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for International League Against Epilepsy . The institution of Dr. Cascino has received research support from Neurelis, Inc.. The institution of Dr. Cascino has received research support from Epilepsy Study Consortium. The institution of Dr. Cascino has received research support from NINDS. Dr. Cascino has received intellectual property interests from a discovery or technology relating to health care. Dr. Cascino has received publishing royalties from a publication relating to health care. Dr. Cascino has received publishing royalties from a publication relating to health care. The institution of Dr. Smith has received research support from CURE Epilepsy.

Increased Perirolandic Cortical Excitability May Facilitate Sensory Motor Mapping in Children (P13-1.003)

<h3>Objective:</h3> We are hereby describing a case of refractory pediatric epilepsy where resection of perirolandic seizure foci was performed successfully under neurophysiologic guidance. <h3>Background:</h3> Pediatric neurophysiologic sensory-motor mapping is frequently unsuccessful, due to inability to localize central sulcus (CS) and primary motor cortex (M1). These shortcomings result from poor somatosensory evoked potentials (SSEP) and high M1 depolarization thresholds respectively, both reflections of the immaturity of the central nervous system. <h3>Design/Methods:</h3> Case report <h3>Results:</h3> An 8-year-old boy with developmental delay, debilitating focal epilepsy and epileptic encephalopathy underwent phase 2 video EEG monitoring. The recordings showed seizures with early involvement of several depth electrodes located within the right parieto-frontal regions, and an early motor semiology involving the left arm. The patient underwent neurophysiologically guided resection of the seizure foci under general anesthesia. Pre-resection electrocorticography (ECoG) via a 64 contact grid showed abundant perirolandic epileptiform discharges (ED), maximal postcentrally. Cortical recordings of high amplitude median SSEP and a low depolarization threshold led to successful CS localization and identification of M1, respectively. A subdural strip electrode placed over the precentral gyrus and secured in position, allowed simultaneous ECoG and motor monitoring during the resection of the postcentral foci. Initially, ECoG showed near continuous runs of ED, unchanged by cortical electrical stimulation. Under steady state anesthesia, at a constant propofol infusion rate, this activity decreased in frequency and stopped altogether towards the end stages of the resection, as the M1 threshold increased by 7 mA. Post-resection fronto-parietal ECoG recordings were quiet. Post-operatively, the patient became seizure free, showed cognitive improvement and no motor deficits. <h3>Conclusions:</h3> Increased cortical excitability may lead to successful functional mapping in children. Under steady anesthetic conditions, increases in the M1 threshold during resection of nearby epileptic foci may be an early sign of decrease in the abnormal regional cortical excitability. <b>Disclosure:</b> Dr. Alzahrany has nothing to disclose. Dr. Simon has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Risk Management Foundation of the Harvard Institutions Incorporated. Dr. Simon has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for MCIC Vermont. Dr. Simon has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Aaronson, Rappaport, Feinstein&amp; Deutch. Dr. Simon has received publishing royalties from a publication relating to health care. Dr. Simon has received personal compensation in the range of $0-$499 for serving as a Speaker with American Clinical Neurophysiology Society . Dr. Simon has a non-compensated relationship as a Speaker with International Society of Intraoperative Neurophysiology that is relevant to AAN interests or activities. Dr. Simon has a non-compensated relationship as a Speaker with Brazilian Congress of Neurology that is relevant to AAN interests or activities.

Evaluation of Automated Seizure Detection Measurements in Cardiac Arrest Patients Undergoing Ceribell Rapid-EEG (S30.009)

<h3>Objective:</h3> To retrospectively evaluate the performance of the Clarity™ automated seizure detection system (Ceribell, Inc) for the detection of seizures and status epilepticus in cardiac arrest patients. <h3>Background:</h3> In cardiac arrest patients who remain comatose after return of spontaneous circulation, seizures and EEG abnormalities are common. Thus, guidelines recommend urgent EEG initiation for evaluation of seizures in this population. Point-of-care EEG systems, such as Ceribell™ Rapid-EEG, allow for prompt initiation of EEG monitoring, albeit through a limited-channel montage. Rapid-EEG incorporates an automated seizure detection software (Clarity™) to measure seizure burden in real time and alert clinicians when a high seizure burden, consistent with possible status epilepticus, is identified. External validation of Clarity is still needed. <h3>Design/Methods:</h3> This study was a retrospective review of Ceribell Rapid-EEG recordings from all the patients who were admitted to the medical intensive care unit at Kent Hospital (Warwick, RI, USA) between 6/1/2021 and 3/18/2022 for management after cardiac arrest and who underwent Rapid-EEG monitoring as part of their routine clinical care (n=21). Board-certified epileptologists identified events that met criteria for seizures or status epilepticus, as per the 2021 American Clinical Neurophysiology Society’s Standardized Critical Care EEG Terminology, and evaluated any seizure burden detections generated by Clarity. <h3>Results:</h3> In this study, 4 of 21 cardiac arrest patients (19.0%) who underwent Rapid-EEG monitoring had multiple electrographic seizures, and 2 of those patients (9.5%) had electrographic status epilepticus within the first 24 hours of the study. None of these ictal abnormalities were detected by the Clarity seizure detection system. Clarity showed 0% seizure burden during all these events. <h3>Conclusions:</h3> The presence of frequent seizures and/or status epilepticus may go undetected by currently available automated seizure detection systems. Timely and careful review of all raw Rapid-EEG recordings by a qualified human EEG reader is necessary to guide clinical care. <b>Disclosure:</b> Dr. Villamar has a non-compensated relationship as a Member of Editorial Board with Neurology: Clinical Practice that is relevant to AAN interests or activities. Dr. Villamar has a non-compensated relationship as a Member of Editorial Board with The Neurohospitalist that is relevant to AAN interests or activities. The institution of Dr. Ayub has received research support from Brown Physicians Incorporated. Dr. Koenig has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Fuji SonoSite. Dr. Koenig has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Medscape.

Editorial introductions.

Current Opinion in Neurology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of neurology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Lawrence J. HirschLawrence J. HirschLawrence J. Hirsch, MD is Professor of Neurology, Chief of the Division of Epilepsy and EEG, and Co-Director of the Comprehensive Epilepsy Center, all at Yale University, USA. He has held leadership positions in the American Clinical Neurophysiology Society (ACNS), American Epilepsy Society, American Academy of Neurology, and the Epilepsy Foundation, and is lead author of the 2012 and 2021 ACNS guidelines on critical care EEG terminology. He is founder and former chair of the Critical Care EEG Monitoring Research Consortium, which now includes more than 50 centers, and co-chair of the medical advisory board of the NORSE Institute. He has been an active researcher throughout his career, having published more than 200 peer-reviewed manuscripts and more than 100 reviews, editorials or book chapters on topics including status epilepticus, all aspects of EEG including intracranial recordings and brain monitoring in the critically ill, brain stimulation, epilepsy surgery, seizure clusters, rescue medications, sudden death in epilepsy (SUDEP), and anti-seizure medication use. He has won multiple teaching awards and is co-author of the first-ever atlas on EEG in critical care, now in its 2nd edition. He continues to see patients in the inpatient and outpatient setting, direct fellowship programs, teach, mentor, and manage a large epilepsy division at a level IV Comprehensive Epilepsy Center. Michael F. WatersMichael F. WatersMichael F. Waters, MD, PhD, is a neurologist, director of both the Neurovascular Division and the Petznick Stroke Center, and a professor in the Department of Neurology at Barrow Neurological Institute, USA. He is board certified in neurology by the American Board of Psychiatry and Neurology with subspecialty board certification in vascular neurology. Dr Waters’ expertise is stroke and neurovascular disease, including signs, symptoms, diagnostics, and treatments. He is a fellow of both the American Academy of Neurology and American Heart Association and a member of the American Neurological Association, American Society of Human Genetics, and the Society of Vascular and Interventional Neurology. Dr Waters received his Masters in genetics from Penn State University in State College, Pennsylvania, USA, and his doctorate in biochemistry and molecular biology from The University of Florida College of Medicine in Gainesville, USA, where he also completed his MD. He completed his residency training at the University of California – Los Angeles Department of Neurology and completed his fellowship in clinical and molecular neurogenetics at Cedars Sinai Medical Center in Los Angeles, USA. Dr Waters’ research studies include genetic mechanisms of stroke, neuroprotection in stroke, stroke treatment, multiple clinical trials investigating stroke treatments, and neurogenetic mechanisms of neuroplasticity.