Head Version Research Articles

Are Metaversion and Glenoid Version Useful in Determining the Humeral Head Version

Are Metaversion and Glenoid Version Useful in Determining the Humeral Head Version

Focal electroclinical features in generalized tonic-clonic seizures: Decision flowchart for a diagnostic challenge.

Bilateral tonic-clonic seizures with focal semiology or focal interictal electroencephalography (EEG) can occur in both focal and generalized epilepsy types, leading to diagnostic errors and inappropriate therapy. We investigated the prevalence and prognostic values of focal features in patients with idiopathic generalized epilepsy (IGE), and we propose a decision flowchart to distinguish between focal and generalized epilepsy in patients with bilateral tonic-clonic seizures and focal EEG or semiology. We retrospectively analyzed video-EEG recordings of 101 bilateral tonic-clonic seizures from 60 patients (18 with IGE, 42 with focal epilepsy). Diagnosis and therapeutic response were extracted after ≥1-year follow-up. The decision flowchart was based on previous observations and assessed concordance between interictal and ictal EEG. Focal semiology in IGE was observed in 75% of seizures and 77.8% of patients, most often corresponding to forced head version (66.7%). In patients with multiple seizures, direction of head version was consistent across seizures. Focal interictal epileptiform discharges (IEDs) were observed in 61.1% of patients with IGE, whereas focal ictal EEG onset only occurred in 13% of seizures and 16.7% of patients. However, later during the seizures, a reproducible pattern of 7-Hz lateralized ictal rhythm was observed in 56% of seizures, associated with contralateral head version. We did not find correlation between presence of focal features and therapeutic response in IGE patients. Our decision flowchart distinguished between focal and generalized epilepsy in patients with bilateral tonic-clonic seizures and focal features with an accuracy of 96.6%. Focal semiology associated with bilateral tonic-clonic seizures and focal IEDs are common features in patients with IGE, but focal ictal EEG onset is rare. None of these focal findings appears to influence therapeutic response. By assessing the concordance between interictal and ictal EEG findings, one can accurately distinguish between focal and generalized epilepsies.

Impact of primary care triage using the Head and Neck Cancer Risk Calculator version 2 on tertiary head and neck services in the post-coronavirus disease 2019 period.

This study investigates the impact of primary care utilisation of a symptom-based head and neck cancer risk calculator (Head and Neck Cancer Risk Calculator version 2) in the post-coronavirus disease 2019 period on the number of primary care referrals and cancer diagnoses. The number of referrals from April 2019 to August 2019 and from April 2020 to July 2020 (pre-calculator) was compared with the number from the period January 2021 to August 2022 (post-calculator) using the chi-square test. The patients' characteristics, referral urgency, triage outcome, Head and Neck Cancer Risk Calculator version 2 score and cancer diagnosis were recorded. In total, 1110 referrals from the pre-calculator period were compared with 1559 from the post-calculator period. Patient characteristics were comparable for both cohorts. More patients were referred on the cancer pathway in the post-calculator cohort (pre-calculator patients 51.1 per cent vs post-calculator 64.0 per cent). The cancer diagnosis rate increased from 2.7 per cent in the pre-calculator cohort to 3.3 per cent in the post-calculator cohort. A lower rate of cancer diagnosis in the non-cancer pathway occurred in the cohort managed using the Head and Neck Cancer Risk Calculator version 2 (10 per cent vs 23 per cent, p = 0.10). Head and Neck Cancer Risk Calculator version 2 demonstrated high sensitivity in cancer diagnosis. Further studies are required to improve the predictive strength of the calculator.

Generalized onset seizures with focal evolution (GOFE) – a largely unknown ictal variation in genetic generalized epilepsies

PurposeAt onset of generalized seizures, focal electroclinical features are commonly seen, while generalized onset seizures with focal evolution (GOFE) are largely unknown bearing the risk of misclassification. MethodsIn two German epilepsy-centers, patients with GOFE documented by video-EEG monitoring (VEM) between 2017 and 2022 were identified retrospectively. In addition to analysis of ictal electroclinical features, detailed epilepsy and family history, response to antiseizure medication (ASM), and findings from neuroimaging were considered. ResultsWe identified five patients with GOFE, three females, age 14 to 22 years. All patients developed genetic generalized epilepsy in childhood or adolescence, each presenting with two or three generalized seizure types. In each of the five patients, one GOFE was recorded by VEM. At onset, EEG seizure patterns were characterized by generalized spike-wave discharges at 2.5 to 3.5/sec for 9 to 16 sec followed by focal evolution of the discharges. Interictally, all patients presented with generalized spike-wave discharges without focal abnormalities. Semiology at onset was behavioral arrest in two patients and generalized increase in tone in one, while two onsets were clinically inapparent. Semiological signs during focal evolution were variable, comprising head and body version, figure 4 sign, unilateral arm clonic activity, and staring with oral automatisms. In one case, focality involved both hemispheres successively. ConclusionProminent focal semiological features in GOFE carry a high risk of misclassification as focal seizures and epilepsy and thus wrong choice of ASM. This calls for low-threshold VEM if any doubts of focal genesis of seizures exist.

AGR - 3 Epilepsy Surgical Planning in a Patient with Co-Morbid Multiple Sclerosis and Seizures.

Research increasingly points to historically unappreciated cortical effects of multiple sclerosis (MS), with two-fold elevated risk of seizures. Nevertheless, epilepsy only occurs in 2-5% of cases. We present a 42-year-old, right-handed, woman with epilepsy and MS under consideration for epilepsy surgery. Epilepsy and MS were diagnosed concurrently at age 31; seizures were the presenting symptom. Despite infrequent MS flares, seizures are weekly-to-monthly focal aware, focal unaware and focal-to-bilateral, starting with right head version, dysarthria, and spinning, followed by secondary generalization, at times occurring in clusters. Brain MRI revealed bilateral MS lesions including in left medial-frontal lobe and left hippocampus (Figure 1). Phase I EEG suggested left-lateralized seizures with broad frontotemporal evolution and rapid bifrontal synchrony. Interictal PET was unrevealing. fMRI determined left-hemisphere language dominance. Neuropsychological evaluation (NPE) was ordered to estimate cognitive risks of left-sided surgery. NPE revealed relatively intact language and verbal learning/memory with exceptionally low visual learning/memory. Visuospatial skills were below average to exceptionally low. Although motor dexterity was exceptionally low bilaterally, her left-hand was markedly slower. Executive functioning, processing speed, and sustained attention were exceptionally low. Risk stratification drew upon traditional epilepsy surgery outcomes, as only 2 cases of epilepsy surgery in vastly different MS patients have been published. NPE suggested high functional adequacy of the left hemisphere with low functional reserve of the right hemisphere. Due to paradoxical findings across structural/functional brain imaging, EEG, and NPE, with unclear effects/implications of MS, cautions were raised about surgery. Stereo-EEG and magnetoencephalography were recommended/ordered to determine the safest surgical option.

Long-Term Quality of Life Following Head and Neck Radiation: A Study Using the Vanderbilt Head and Neck Symptom Survey

Head and neck (H&N) radiation (RT) is characterized by significant acute toxicity, but long-term quality of life (QoL) following H&N RT is not well defined. This study sought to prospectively characterize, by subsite, long-term QoL in patients who underwent H&N RT using the Vanderbilt Head and Neck Symptom Survey (VHNSS) version 2.0. In patients treated with H&N RT between 2010 and 2021, the VHNSS was prospectively collected prior to beginning RT and at follow-up visits after completion of RT. Responses were broken down into symptom clusters for characterization of specific side effects and scored from 0 (asymptomatic) to 10 (severe symptoms). Patients were stratified by disease site and type of RT, with three main subgroups of interest: p16+ oropharynx (OPX) treated with definitive RT, nasopharynx (NPX) treated with definitive RT, and oral cavity (OC) treated with postoperative RT (PORT). To characterize long-term QoL, surveys collected 2 years (±3 months) after completion of RT were analyzed. Survey response distributions are reported as median and interquartile ranges. Comparisons between groups were made using the Mann-Whitney U test. A total of 65 patients (33 OPX [50.8%], 19 NPX [29.2%], 13 OC [20.0%]) had survey responses at 2 years. Median age was 56 (range 20-86). 48 (73.8%) patients were male. Concurrent chemotherapy was administered to 52 patients (80.0%). At 2 years, among OPX patients, trouble hearing (1.5 [0-5]) represented the greatest symptom burden, though this was still less than NPX (4.0 [2.0-7.5]; p = 0.099) patients but greater than OC (0.0 [0.0-1.5]; p = 0.16) patients. OPX patients had significantly less difficulty swallowing solids (0.8 [0.1-2.0]) compared to NPX (2.5 [1.1-5.1]; p = 0.018) and OC (3.5 [1.9-5.1]; p = 0.002) patients. OPX patients also experienced less dry mouth (1.0 [0.2-3.3]) than NPX (3.2 [1.5-6.6]; p = 0.012) and OC (2.4 [1.8-5.4]; p = 0.056) patients. OPX patients reported less trismus (0.0 [0.0-0.2]) than NPX (4.0 [0.0-7.0]; p<0.001) and OC (1.0 [0.5-3]; p = 0.002) patients. OPX patients had less neck tightness (0.0 [0.0-2.0]) than NPX (2.0 [0.0-3.0]; p = 0.022) patients and less voice dysfunction (0.0 [0.0-0.7]) than OC (3.0 [1.2-3.5]; p = 0.011) patients. Lastly, OPX patients had better mental health (0.0 [0.0-1.2]) than NPX (2.0 [0.0-5.0]; p = 0.019) and OC (2.0 [0.0-3.2]; p = 0.086) patients. There was no difference in taste/smell among OPX (0.9 [0.0-2.7]), NPX (2.3 [0.7-5.1]; p = 0.100), and OC (1.5 [1.1-3.4]; p = 0.230) patients. The VHNSS was able to characterize long-term QoL in patients treated with H&N RT. In general, patients with OPX treated with definitive RT have improved long-term QoL relative to patients with NPX or OC cancers, though at least a quarter of patients still report significant dry mouth, taste/smell, and hearing difficulties. Additional work should seek to identify, and, where possible through timely rehabilitation, proactively mitigate late symptoms in patients following H&N RT.

Coronavirus disease 2019 pandemic telephone two-week-wait referrals in head and neck cancer - how safe were they?

During the coronavirus disease 2019 pandemic, ENT-UK recommended a move from face-to-face clinics to telephone appointments. This study reviewed the safety of telephone clinics for urgent two-week-wait cancer referrals. Patients consulted in telephone clinics between April and November 2020 were identified from an electronic database. Study patients included those diagnosed with malignant disease at six months. The Head and Neck Cancer Risk Calculator version 2 score, outcome of the initial clinic and final diagnoses were reviewed. A total of 1062 patients were triaged in clinic; 9.2 per cent (n = 98) were diagnosed with cancer at 6 months. Of these 98 patients, 69 received an urgent face-to-face appointment, 26 underwent urgent scans and 3 had a delayed telephone review. Twenty patients (20.4 per cent) diagnosed with cancer had a low-risk Head and Neck Cancer Risk Calculator score. The late diagnosis rate of 0.28 per cent suggests a small proportion of cancer could have been missed. Telephone clinics, whilst a pragmatic means to maintain patient flow during the pandemic, could result in late diagnoses.

Accuracy of the Head and Neck Cancer Risk Calculator in identifying maxillofacial malignancies

The OMFS urgent suspicion of cancer (USOC) referral pathway for head and neck cancer is costly in terms of time and resources, and despite NICE referral guidance, it has a low conversion rate with many inappropriate referrals. The Head and Neck Cancer Risk Calculator version 2 (HaNC-RC-v2) gives recommendations to primary care referrers on appropriate referral priority. To our knowledge, this is the first study to investigate the accuracy of the HaNC-RC-v2 in a cohort of maxillofacial referrals. Electronic patient records were reviewed for all malignancies diagnosed by OMFS in 2019 (n = 54), and a sample of USOC referrals to OMFS (n = 204). The HaNC-RC-v2 was applied to each patient, using information from the referral letter and the clinical notes from the new patient consultation. The mean and median HaNC-RC-v2 scores for patients with malignancy were 42.22% and 32.23%, respectively. For patients without malignancy, mean and median scores were 9.27% and 5.68%, respectively. There was a statistically significant relation between the presence/absence of malignancy and the recommendation made by the risk calculator (p = 0.0012). The calculator recommended USOC referral for 76% (41/54) of patients with malignancy, and only 41% (83/204) of patients without malignancy. The negative predictive value of the HaNC-RC-v2 was 99.2%. The calculator has the potential to reduce the number of inappropriate referrals to OMFS via the USOC pathway.

Primary care triaging of head and neck cancer referrals using the head and neck cancer risk calculator version 2: impact on a tertiary head and neck service.

This study aimed to investigate the use of the head and neck cancer risk calculator version 2 in a primary care setting and to evaluate the impact of the risk calculator on the number of referrals stratified by urgency and cancer yield. Referrals between April 2019 and August 2019, April 2020 and July 2020 (pre-risk calculator) and August 2020 and July 2021 (post-risk calculator) were analysed. Referral urgency, head and neck cancer risk calculator version 2 score, cancer diagnosis, cancer type and further investigations were recorded. The 2023 patient encounters were analysed; there were 1110 (55 per cent) referrals before head and neck cancer risk calculator version 2 use and 913 (45 per cent) after head and neck cancer risk calculator version 2 use. A higher proportion of older (p < 0.001) and male (p < 0.013) patients were seen post-head and neck cancer risk calculator version 2 use. All cancer cases were seen on the urgent suspicion of cancer pathway post-head and neck cancer risk calculator version 2 use; however, a higher proportion of patients were seen as urgent suspicion of cancer (51.1 vs 83.5 per cent; p < 0.001). Overall, the cancer diagnosis rate increased from 2.7 to 4.1 per cent. The head and neck cancer risk calculator version 2 had high sensitivity in cancer diagnosis. More studies are required to optimise the predicted versus actual cancer probability gap.

Semiologic differences between bilateral tonic-clonic seizures of focal onset and generalized onset

BackgroundFocal semiologies have been described in idiopathic generalized epilepsies (IGE) and generalized-onset bilateral tonic-clonic seizures (GBTCS). These focal signs may lead to wrong diagnosis and inappropriate choice of antiseizure medications. We sought to investigate the differences in focal semiologic features between GBTCS and focal-onset bilateral tonic-clonic seizures (FBTCS). MethodsWe retrospectively reviewed video-EEG data of captured GBTCS and FBTCS over a period of five years. The presence or absence of 12 focal signs as well seizure duration and time to head version was tabulated for each seizure. We used the chi-square test for independence and Fisher’s exact test to investigate the occurrence of each focal sign in FBTCS compared with GBTCS. Additionally, we used receiver operating characteristic (ROC) curves to explore if the seizure duration and time to head version from the ictal onset can reliably differentiate between FBTCS and GBTCS. Finally, we employed hierarchical cluster analysis to visualize how these focal signs appear in combination. ResultsHead version (p <.001), preceding automatisms (p <.001), eye version (p <.001), unilateral facial clonic activity (p <.001), and mouth deviation (p =.004) were found to be significantly more frequent in FBTCS. Longer seizures were highly in favor of FBTCS whereas shorter time to head version from the ictal onset indicated GBTCS in the ROC curve analysis. ConclusionsThough focal signs occur in GBTCS, careful evaluation of semiology can help the clinician distinguish FBTCS from GBTCS.

Probabilistic landscape of seizure semiology localizing values.

Semiology describes the evolution of symptoms and signs during epileptic seizures and contributes to the evaluation of individuals with focal drug-resistant epilepsy for curative resection. Semiology varies in complexity from elementary sensorimotor seizures arising from primary cortex to complex behaviours and automatisms emerging from distributed cerebral networks. Detailed semiology interpreted by expert epileptologists may point towards the likely site of seizure onset, but this process is subjective. No study has captured the variances in semiological localizing values in a data-driven manner to allow objective and probabilistic determinations of implicated networks and nodes. We curated an open data set from the epilepsy literature, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, linking semiology to hierarchical brain localizations. A total of 11 230 data points were collected from 4643 patients across 309 articles, labelled using ground truths (postoperative seizure-freedom, concordance of imaging and neurophysiology, and/or invasive EEG) and a designation method that distinguished between semiologies arising from a predefined cortical region and descriptions of neuroanatomical localizations responsible for generating a particular semiology. This allowed us to mitigate temporal lobe publication bias by filtering studies that preselected patients based on prior knowledge of their seizure foci. Using this data set, we describe the probabilistic landscape of semiological localizing values as forest plots at the resolution of seven major brain regions: temporal, frontal, cingulate, parietal, occipital, insula, and hypothalamus, and five temporal subregions. We evaluated the intrinsic value of any one semiology over all other ictal manifestations. For example, epigastric auras implicated the temporal lobe with 83% probability when not accounting for the publication bias that favoured temporal lobe epilepsies. Unbiased results for a prior distribution of cortical localizations revised the prevalence of temporal lobe epilepsies from 66% to 44%. Therefore, knowledge about the presence of epigastric auras updates localization to the temporal lobe with an odds ratio (OR) of 2.4 [CI95% (1.9, 2.9); and specifically, mesial temporal structures OR: 2.8 (2.3, 2.9)], attesting the value of epigastric auras. As a further example, although head version is thought to implicate the frontal lobes, it did not add localizing value compared with the prior distribution of cortical localizations [OR: 0.9 (0.7, 1.2)]. Objectification of the localizing values of the 12 most common semiologies provides a complementary view of brain dysfunction to that of lesion-deficit mappings, as instead of linking brain regions to phenotypic-deficits, semiological phenotypes are linked back to brain sources. This work enables coupling of seizure propagation with ictal manifestations, and clinical support algorithms for localizing seizure phenotypes.

Teaching NeuroImage: Drug Refractory Epilepsy With Developmental Dysarthria Due to Bilateral Perisylvian Polymicrogyria.

A 15-year-old boy presented with 5 years of refractory focal seizures with 4–6 episodes per day. The seizure semiology was described as numbness of the left half of the body followed by tonic posturing and head version to left with loss of awareness lasting for 30 seconds. Additional symptoms included cognitive impairment with delayed and dysarthric speech. Neuropsychological assessment revealed impaired intellectual and cognitive ability. MRI of the brain demonstrated bilateral perisylvian polymicrogyria (Figure, A–C). BPP is a cortical development malformation1 characterized by widened Sylvian fissures with an increased number of abnormally small gyri and shallow sulci. Patients present with dysarthria and refractory seizures.2

A comparison of patient-specific instrumentation to navigation for conducting humeral head osteotomies during shoulder arthroplasty.

BackgroundThe humeral head osteotomy during shoulder arthroplasty influences humeral component height, version and possibly neck-shaft angle. These parameters all potentially influence outcomes of anatomic and reverse shoulder replacement to a variable degree. Patient-specific guides and navigation have been studied and utilized clinically for glenoid component placement. Little, however, has been done to evaluate these techniques for humeral head osteotomies. The purpose of this study, therefore, was to evaluate the use of patient-specific guides and surgical navigation for executing a planned humeral head osteotomy.MethodsThe DICOM images of 10 shoulder computed tomography scans (5 normal and 5 osteoarthritic) were used to print 3D polylactic models of the humerus. Each model was duplicated, such that there were 2 identical groups of 10 models. After preoperative planning of a humeral head osteotomy, Group 1 underwent osteotomy via a patient-specific guide, while group 2 underwent a real time navigated osteotomy with an optically tracked sagittal saw. The cut height (millimeters), version (degrees) and neck-shaft angle (degrees) were recorded and statistically compared between groups.ResultsThere were no statistically significant differences between patient-specific guides and navigation for osteotomy cut height (P = .45) and humeral version (P = .059). Navigation, however, resulted in significantly less neck-shaft angle error than the patient specific guides (P = .023). Subgroup analysis of the osteoarthritic cases showed statistical significance for navigation resulting in less version error than the patient specific guides (P = .048).ConclusionNo significant differences were found between patient specific guides and navigation for recreation of the preoperatively planned humeral head cut height and version. Neck-shaft angle, however, had significantly less deviation from the preoperative plan when conducted with navigation.

Telephone triage of suspected head and neck cancer patients during the coronavirus disease 2019 pandemic using the Head and Neck Cancer Risk Calculator version 2.

Utilisation of the Head and Neck Cancer Risk Calculator version 2 has been recommended during the coronavirus disease 2019 pandemic for the assessment of head and neck cancer referrals. As limited data were available, this study was conducted to analyse the use of the Head and Neck Cancer Risk Calculator version 2 in clinical practice. Patients undergoing telephone triage in a two-week wait referral clinic were included. Data were collected and analysed using appropriate methods. Sixty-four patients in the study were risk-stratified into low-risk (51.6 per cent, 33 of 64), moderate-risk (14.1 per cent, 9 of 64) and high-risk (34.4 per cent, 22 of 64) groups. Of the patients, 53.1 per cent (34 of 64) avoided an urgent hospital visit, and 96.9 per cent (62 of 64) were cancer free, while 3.1 per cent (2 of 64) were found to have a head and neck malignancy. The sensitivity, specificity, negative predictive value and accuracy were 50.00 per cent, 66.13 per cent, 99.92 per cent and 66.11 per cent, respectively. It is reasonable to use the calculator for triaging purposes, but it must always be accompanied by a meticulous clinical thought process.

Translation and cross-cultural adaption of the Chinese version of the Vanderbilt Head and Neck Symptom Survey version 2.0: a tool for oral symptom assessment in head and neck cancer patients

BackgroundPatients with head and neck cancer (HNC) who are receiving radiotherapy commonly face detrimental complications, including oral issues. However, oral symptoms are not well understood given the lack of available specific assessment instruments. The Vanderbilt Head and Neck Symptom Survey version (VHNSS) 2.0 is an instrument specifically developed to identify oral symptoms in HNC patients receiving radiotherapy in the United States.ObjectiveTo perform the translation and cross-cultural adaptation of the original English version of VHNSS 2.0 into a Chinese version (Mainland China).MethodsThe translation and cultural adaptation process involved translation by independent translators, construction of a consensus version, back translation into the original English version, analysis by the expert committee and a pretest. The pretest was administered to 90 patients with HNC to assess the feasibility and practicality of the tool.ResultsThe final Chinese version approved by the expert committee was well understood by all participants in the study. The instrument had satisfactory content validity, with indexes of 0.83 for semantic and idiomatic equivalence, 0.90 for cultural equivalence, and 0.91 for conceptual equivalence. Furthermore, this version had good internal consistency, with Cronbach's alpha coefficients ranging from 0.74 to 0.95.ConclusionThe Chinese version of VHNSS 2.0 was translated and cross-culturally adapted for use in China. This translation is a feasible instrument to assess oral health-related quality of life in HNC patients undergoing radiotherapy and will be useful for symptom management by clinicians and researchers in China.

Segmental Myoclonus Following Hepatorenal Transplant and Tacrolimus Immunosuppression

This 16-year-old girl with methylmalonic acidemia complicated by chronic kidney disease underwent hepatorenal transplantation with an uneventful postoperative course. She was discharged on prednisone, mycophenolate mofetil, tacrolimus, trimethoprim-sulfamethoxazole, and valganciclovir. Her peak trough of tacrolimus during initiation was 17.1 ng/mL (goal: 10 to 15 ng/mL). At 1.5 weeks after transplant she developed intermittent “jerking” about her abdominal incision. Soon after, she slumped, developed rightward head version with right face/eyelid twitching, and became unresponsive with generalized tremulousness for two minutes.

Network of ictal head version in mesial temporal lobe epilepsy.

ObjectiveIctal head version is a common clinical manifestation of mesial temporal lobe epilepsy (MTLE). Nevertheless, the location of the symptomatogenic zone and the network involved in head version remains unclear. We attempt to explain these problems by analyzing interictal 18FDG‐PET imaging and ictal stereo‐electroencephalography (SEEG) recordings in MTLE patients.MethodsFifty‐eight patients with MTLE were retrospectively analyzed. The patients were divided into version (+) and (−) groups according to the occurrence of versive head movements. The interictal PET data were compared among 18 healthy controls and the (+) and (−) groups. Furthermore, epileptogenicity index (EI) values and correlations with the onset time of head version were analyzed with SEEG.ResultsIntergroup comparisons showed that PET differences were observed in the middle temporal neocortex (MTN), posterior temporal neocortex (PTN), supramarginal gyrus (SMG), and inferior parietal lobe (IPL). The EI values in the SMG, MTN, and PTN were significantly higher in the version (+) group than in the version (−) group. A linear relationship was observed between head version onset and ipsilateral onset time in the SMG, orbitofrontal cortex (OFC), MTN, and PTN. A linear relationship was observed between EI, the difference between version onset and temporal neocortex onset, and the y‐axis of the MNI coordinate.ConclusionThe generation of ictal head version contributes to the propagation of ictal discharges to the intraparietal sulcus (IPS) area. The network of version originates from a mesial temporal lobe structure, passes through the MTN, PTN, and SMG, and likely ends at the IPS.

A pilot study on the Vanderbilt head and neck symptom survey Italian version (VHNSS-IT) to test its feasibility and utility in routine clinical practice.

Patient-reported outcome measures can be useful to assess symptoms in head and neck cancer (HNC) patients treated with radio-chemotherapy. This is a pilot study on the VHNSS-IT (the Italian version of the Vanderbilt head and neck symptom survey) performed to assess both the feasibility and utility of its administration in clinical practice. The outcomes analyzed were feasibility to recruit patients, feasibility to complete the questionnaire, feasibility to review the questionnaire, utility perceived by clinicians, distribution of patient's answers reflecting symptom's intensity. Among the 38 patients enrolled, 37 completed the VHNSS-IT (refusal rate 2.6%). Median time of completion was 6'57″. Time of completion was influenced by age (p = 0.002), grade of education (p = 0.023) and employment status (p = 0.004). Time after the start of the radiotherapy course (< 6months vs. > 6months) and surgery (yes vs. no) influenced symptoms' intensity. Median time for review was 2'15″. Time burden was perceived to be acceptable for all clinicians; they all also found the questionnaire easy to use. Rates of global perceived utility and future intention to use the questionnaire were 100%. The VHNSS-IT has demonstrated to be a useful measurement of symptoms' burden for patients with HNC. The survey can be easily completed during the clinic routine without interfering with doctors' visits schedule, and it can help healthcare providers to identify symptoms that require referral, education or intervention.

Superior Frontal Sulcus Focal Cortical Dysplasia Type II: An MRI, PET, and Quantified SEEG Study.

Purpose: The superior frontal sulcus (SFS), located in the prefrontal and premotor cortex, is considered as one of the common locations of focal cortical dysplasia (FCD). However, the characteristics of seizures arising from this area are incompletely known. The primary purpose of this study was to investigate the clinical features and the epileptic networks of seizures originating from the SFS.Methods: We included seventeen patients with type II FCD within the SFS. SFS was identified both visually and automatically. Semiological features were evaluated and grouped. Interictal 18FDG-PET imaging in all patients was compared to controls using statistical parametric mapping (SPM-PET). In those subjects with stereoelectroencephalography (SEEG), two different quantitative intracranial electroencephalography analyses were applied. Finally, the locations of the SFS-related hypometabolic regions and epileptogenic zones (EZs) were transformed into standard space for group analysis.Results: We identified two semiological groups. Group 1 (9/17) showed elementary motor signs (head version and tonic posturing), while group 2 (8/17) exhibited complex motor behavior (fear, hypermotor, and ictal pouting). Based on SPM-PET, an SFS-supplementary motor area (SMA) epileptic propagation network was found in group 1, and an SFS-middle cingulate cortex (MCC)-pregenual anterior cingulate cortex (pACC) propagation network was discovered in group 2. Intracranial EEG analysis suggested similar affected structures with high epileptogenicity. The SFS-related hypometabolic regions and EZs in these groups showed a posterior-anterior spatial relationship.Conclusions: Even though originating from the spatially restricted cortex, SFS seizures can be divided into two groups based on semiological features. The SFS-SMA and SFS-MCC-pACC epileptic propagation networks may play pivotal roles in the generation of different semiologies. The posterior-anterior spatial relationship of both hypometabolic regions and EZs provides potentially useful information for distinguishing different types of SFS seizures and surgical evaluation.

Acquired epileptiform opercular syndrome evaluated with real-time transcranial Doppler ultrasound-video-electroencephalogram before and after treatment: a case report

BackgroundAcquired epileptiform opercular syndrome (AEOS) with electrical status epilepticus during sleep (ESES) may be recurrent and intractable. The real-time transcranial Doppler ultrasound–sleep-deprived video electroencephalogram (TCD-SDvEEG) can be used to observe the relationships among hemodynamic, electrophysiological, and clinical factors in a patient during therapy. This study reported the case of a healthy 5-year-old boy with AEOS.Case presentationThe patient had initial seizures during sleep at the age of 1 year, with the left mouth pouting, left eye blinking and drooling for several seconds, and, sometimes, the left upper-limb flexion and head version to the left, lasting for 1–2 min. The combined antiepileptic drug regimens, including valproate, lamotrigine, and clonazepam, failed in the present case. Therefore, the add-on high-dose methylprednisolone therapy was provided. Also, the serial TCD-SDvEEG was used to monitor the dynamic changes before and after add-on steroid treatment. The results showed less than 15% variation in the range of blood flow fluctuation with spikes during non-rapid eye movement sleep after treatment. This was similar to the outcomes in healthy children and also accorded with the clinical improvements such as seizure control, drooling control, and language ability melioration. However, 95% of spike-wave index (SWI) was still maintained. The improvements in cerebral hemodynamics and clinical manifestations were faster and earlier than the SWI progression.ConclusionsThe real-time TCD-SDvEEG was highly sensitive in detecting therapeutic changes. The findings might facilitate the understanding of the mechanisms underlying neurovascular coupling in patients with AEOS accompanied by ESES.