Triphasic Waves Research Articles

Prognostic value of early EEG abnormalities in severe stroke patients requiring mechanical ventilation: a pre-planned analysis of the SPICE prospective multicenter study

IntroductionPrognostication of outcome in severe stroke patients necessitating invasive mechanical ventilation poses significant challenges. The objective of this study was to assess the prognostic significance and prevalence of early electroencephalogram (EEG) abnormalities in adult stroke patients receiving mechanical ventilation.MethodsThis study is a pre-planned ancillary investigation within the prospective multicenter SPICE cohort study (2017–2019), conducted in 33 intensive care units (ICUs) in the Paris area, France. We included adult stroke patients requiring invasive mechanical ventilation, who underwent at least one intermittent EEG examination during their ICU stay. The primary endpoint was the functional neurological outcome at one year, determined using the modified Rankin scale (mRS), and dichotomized as unfavorable (mRS 4–6, indicating severe disability or death) or favorable (mRS 0–3). Multivariable regression analyses were employed to identify EEG abnormalities associated with functional outcomes.ResultsOf the 364 patients enrolled in the SPICE study, 153 patients (49 ischemic strokes, 52 intracranial hemorrhages, and 52 subarachnoid hemorrhages) underwent at least one EEG at a median time of 4 (interquartile range 2–7) days post-stroke. Rates of diffuse slowing (70% vs. 63%, p = 0.37), focal slowing (38% vs. 32%, p = 0.15), periodic discharges (2.3% vs. 3.7%, p = 0.9), and electrographic seizures (4.5% vs. 3.7%, p = 0.4) were comparable between patients with unfavorable and favorable outcomes. Following adjustment for potential confounders, an unreactive EEG background to auditory and pain stimulations (OR 6.02, 95% CI 2.27–15.99) was independently associated with unfavorable outcomes. An unreactive EEG predicted unfavorable outcome with a specificity of 48% (95% CI 40–56), sensitivity of 79% (95% CI 72–85), and positive predictive value (PPV) of 74% (95% CI 67–81). Conversely, a benign EEG (defined as continuous and reactive background activity without seizure, periodic discharges, triphasic waves, or burst suppression) predicted favorable outcome with a specificity of 89% (95% CI 84–94), and a sensitivity of 37% (95% CI 30–45).ConclusionThe absence of EEG reactivity independently predicts unfavorable outcomes at one year in severe stroke patients requiring mechanical ventilation in the ICU, although its prognostic value remains limited. Conversely, a benign EEG pattern was associated with a favorable outcome.

Stimulus-induced arousal with transient electroencephalographic improvement distinguishes nonictal from ictal generalized periodic discharges.

In the case of suspicion of nonconvulsive status epilepticus (NCSE), reactivity on electroencephalograms (EEGs) can provide valuable diagnostic information. Reactivity refers to responses to auditory or somatosensory stimulation, with changes in amplitude and frequency of background activity. Because of self-perpetuating processes and the failure of self-terminating mechanisms, status epilepticus is unlikely to cease when patients spontaneously move, and it cannot typically be stopped by external stimulation (i.e., auditory and tactile stimuli). The defining EEG characteristic of absence status epilepticus is the presence of bilateral, synchronous, symmetric, rhythmic paroxysmal activity that shows little or no reactivity to sensory stimulation. On the other hand, in metabolic/toxic or multifactorial encephalopathies, triphasic waves (TWs) are influenced by the level of vigilance. TWs may be transiently abolished when patients increase their level of alertness from a drowsy/lethargic state to a state of wakefulness. This reactivity is only observed when patients can be aroused by a somatosensory or auditory stimulus. This reactivity tends to disappear with increasing severity of the disease and in comatose patients. In patients without preexisting developmental and epileptic encephalopathy, this pattern of stimulus-induced wakefulness with transient improvement of the EEG is a major criterion in determining that the EEG patterns are not ictal. This criterion of reactivity on EEGs, beyond the classical clinical/EEG criteria of NCSE (Salzburg criteria), should now be systematically added.

Neurotoxic effects of a well known antibiotic!

To the Editor, Cefepime is a fourth-generation cephalosporin with broad-spectrum antimicrobial activity covering a wide range of both gram-negative and gram positive organisms. It is administered parenterally to treat pneumonia, urinary tract infections as well as skin and soft tissue infections. It is generally well tolerated with the most commonly reported side effects being diarrhea and rash. However, cefepime induced neurotoxicity is a rare but life- threatening adverse effect that, despite being described in literature, is often overlooked. According to the literature, about 15% of ICU patients managed with cefepime may develop neurological symptoms, including altered consciousness, aphasia, myoclonus, encephalopathy, seizures and coma. EEG abnormalities such as non-convulsive status epilepticus, myoclonic status epilepticus, triphasic waves and focal sharp waves have also been reported. Risk factors for cefepime neurotoxicity include renal function impairment, overdosing, previous brain injury and elevated serum cefepime concentrations.1 A case study published in 2021 reported a rare case of cefepime induced neurotoxicity where an elderly female suffering from chronic renal transplant rejection was given cefepime. Despite renal dosage adjustment, the patient developed neurotoxicity and presented with acute delirium, inability to tolerate oral intake and non-convulsive status epilepticus on EEG. Discontinuation of cefepime resulted in improvement of symptoms.2 Another case series published in 2017 reported cefepime induced neurotoxicity in 3 patients, one of whom had normal kidney function. These patients presented with asynchronous myoclonus and expressive aphasia.3 Considering the common use of cefepime in hospital settings, it is very important to heed the possible neurological adverse effects of this antibiotic which can be potentially fatal. Cefepime should be used with caution especially in individuals with preexisting renal impairment. Fortunately, cefepime neurotoxicity is reversible and usually resolves with discontinuation of the drug. In a few cases, dialysis may be needed to hasten the elimination of the drug.4 Anticonvulsants may be needed if patient presents with seizures or non-convulsive status epilepticus.5 Since treatment is simple and recovery rates are good, prompt recognition is crucial. Especially in ICU patients, recognition of cefepime induced neurotoxicity is challenging as it may present with neurological symptoms that are common in critically ill patients. Therefore, ICU patients receiving cefepime should be closely monitored. It is of vital importance to raise awareness regarding the neurotoxic effects of cefepime to facilitate early recognition which will help reduce morbidity and mortality associated with this drug.

Hypsarrhythmia and triphasic waves seem to be akin(similar) age-dependent responses of the brain to different insults.

Hypsarrhythmia and triphasic waves seem to be akin(similar) age-dependent responses of the brain to different insults.

COVID-19 encephalopathy with severe neurological symptoms: a clinical case presentation with literature review

COVID-19 infection is affecting more and more people around the world, and as the number of recovered patients increases, so does the knowledge on the potential clinical signs of the disease. Although SARS-CoV-2 virus is commonly associated with damage to the respiratory system, it has been observed that about half of patients with COVID-19 infection may also develop various neurological symptoms such as anosmia, dysgeusia, headache, myalgia, or dizziness. Encephalopathy is singled out as one of the most severe complications of the central nervous system caused by SARS-CoV-2 virus and associated with longer duration of the disease, increased disability, and mortality. Acute encephalopathy is a disorder of the brain that clinically occurs with a sudden change in the level of consciousness in otherwise healthy patients before the onset of symptoms. Risk factors include older age, male gender, quicker hospitalization after the onset of symptoms, and chronic illnesses. In exceptional cases, encephalopathy may be an early or even a major symptom of COVID-19 in young patients. The pathogenesis of COVID-19 encephalopathy is not fully understood. However, the most likely etiology of encephalopathy is multifactorial: systemic disease response, inflammation, coagulopathy, direct viral neuroinvasion, endoartheritis, and possibly post-infectious autoimmune mechanisms. For patients with suspected changes in the level of consciousness due to coronavirus infection, it is recommended to perform a thorough examination of the cerebrospinal fluid (CSF), head imaging with a preference for magnetic resonance imaging (MRI), and electroencephalography (EEG) It is worth noting that blood or imaging tests often do not show specific changes in patients with encephalopathy. As revealed by some studies of CSF examinations, cytosis is usually absent or very low while the protein concentration remains normal. It is important to note that SARS-CoV-2 is detected in the cerebral fluid only in isolated cases. Although the EEG of patients with COVID-19 are often normal, they sometimes show specific encephalopathic changes including excessive generalized frontal delta waves, triphasic waves and lower amplitude alpha and beta waves. The MRI describes a spectrum of neurovisual abnormalities, the most common of which are foci of leukoencephalopathy, changes in diffusion restriction imaging in the white, rarely in the gray matter, signs of microhaemorrhage and leptomeningitis. Treatment for COVID-19 encephalopathy includes supportive care and symptomatic treatment. Some studies have shown that immune modulation therapy, including high-dose corticosteroids and intravenous immunoglobulins, is effective in some severely ill patients.

Tagging EEG features within exam reports to quickly generate databases for research purposes

Objectiveassess the effectiveness of a new method for classifying EEG recording features through the use of tags within reports. We present feature prevalence in a sample of patients with toxic-metabolic encephalopathy and discuss the advantages of this approach over existing classification systems. Methodsduring EEG report creation, tags reflecting background activity, epileptiform features and periodic discharges were selected according to the findings of each recording. Reports including the tags have been collected and processed by the EEG report parser script written in PHP language. The resulting spreadsheet was analysed to calculate the prevalence and type of EEG features in a sample group of patients with toxic-metabolic encephalopathy. Resultstag checking and extraction were very little time-consuming processes. Considering 5784 EEG recordings performed either in inpatients or outpatients over 2 years, toxic-metabolic aetiology was tagged in 218 (3.8 %). The most frequent background feature was severe slowing (5–6 Hz frequency), occurring in 79 (36.2 %). Epileptiform abnormalities were rare, reaching a maximum of 10 (4.6 %). Triphasic waves were tagged in 43 (19.7 %) recordings. Conclusionstagging and parsing processes are very fast and integrated into the daily routine. Sample analysis in patients with toxic-metabolic encephalopathies showed EEG slowing as the prevalent feature, while triphasic waves occurred in a minority of recordings. Existing software such as “SCORE” (Holberg EEG) requires the replacement of the currently used software for EEG reporting, minimizing additional costs and training. EEG Report Parser is free and open-source software, so it can be freely adopted, modified and redistributed, allowing further improvement and adaptability.

Association Of Electroencephalogram Patterns With Ammonia Levels In Hepatic Encephalopathy Patients

Objective: To find out the association between electroencephalogram (EEG) and hepatic encephalopathy.
 Methodology: This cross-sectional study included 100 patients (with the age of52.5±6.09years for males and 51.7 ± 6.10 years for females) of reported hepatic encephalopathy, visiting the medical department (indoor and OPD) at Federal Government Polyclinic Hospital, Islamabad. The study was conducted from January 2020 to May 2021. Patients who had known epileptic and structural brain lesions or strokes were excluded from the study. Statistical analysis was done using GraphPad Prism software. The significance of data (p-value or R2 value) was calculated through a two-tailed test or correlation coefficient.
 Results: All the patients in hepatic encephalopathy grade IV reported abnormal EEG representing triphasic waves and flattening of EEG pattern. There was no correlation observed between age, gender and hepatic encephalopathy grades. However, a significant correlation (R2= 0.9032) was observed between serum ammonia levels and hepatic encephalopathy grades. Elevated serum ammonia levels depicted the severity of hepatic encephalopathy. Overall, the percentage of patients with abnormal EEG increased with increasing grade of hepatic encephalopathy. It was quite intriguing to note that EEG, being the common method to diagnose hepatic encephalopathy grades, is not dependent on patients’ socio-economic status.
 Conclusion: Data concluded that serum ammonia levels are well associated with the progression of hepatic encephalopathy. Moreover, the EEG patter provides the appropriate information about the neurological abnormalities associated with the severity of hepatic encephalopathy. Hence, serum ammonia levels and EEG both should accurately be used as indicators for diagnosis and monitoring the response to the treatment of various grades of hepatic encephalopathy. Data warrant further investigations to get a better insight into hepatic encephalopathy's relationship with EEG patterns through the inclusion of molecular parameters.

Forma esporádica de enfermedad de Creutzfeldt-Jakob: reporte de dos casos

La enfermedad de Creutzfeldt-Jakob es la encefalopatía espongiforme más común en el ser humano y prototipo de las patologías causadas por priones. Se caracteriza histológicamente por astrogliosis y degeneración de la sustancia gris. Típicamente inicia con síntomas prodrómicos no específicos progresando a demencia con mioclonias y ataxia. Presentamos dos casos de mujeres en edad media con deterioro cognitivo progresivo, dificultades motrices, alteraciones del lenguaje y mioclonias que conducen a la muerte. En electroencefalogramas de ondas trifásicas lentas periódicas así como elevación de proteínas tau y 14-3-3 en LCR por apoyo del The National Prion Disease Pathology Surveillance Center - Cleveland, todos estos hallazgos definen las condiciones para el diagnóstico clínico de enfermedad por priones. El diagnóstico diferencial en el contexto de demencia rápidamente progresiva es amplio, incluyendo infecciones, intoxicaciones, trastornos metabólicos, autoinmunidad, vasculopatías y neoplasias que podrían explicar un posible subregistro en las estadísticas regionales. Existe una posible asociación de riesgo entre enfermedad por priones y médicos patólogos que, aunque discutida, podría limitar el estudio de los especímenes histológicos que son la clave del diagnóstico definitivo. A pesar de la importancia en salud pública de estas condiciones, el actual modelo de salud limita el manejo integral de los pacientes.

Spectrum and Pattern of Movement Disorders in Patients with Sporadic Creutzfeldt-Jakob Disease.

Creutzfeldt-Jakob disease (CJD) is a rare neuro degenerative disease that is mainly characterized by rapidly progressive dementia along with a varying combination of myoclonus, visual, cerebellar, pyramidal/extrapyramidal and akinetic mutism. Several movement disorders phenomenologies can occurs either at onset, as presenting symptom or during the course of illness. Present study aims to characterize the clinical, radiological features and the outcome of patients with CJD with movement disorders as the forthcoming manifestation. Chart review of patients with CJD with movement disorders. Demographic, clinical and radiological details of the patients were reviewed. 25 patients (13 males) of sCJD with median age at presentation of 58 years and median duration of illness of 5 months were included in the study. According to revised CDC diagnostic criteria 1 patient was classified as definite sCJD, 20 as probable and 2 as possible CJD. Myoclonus, ataxia and parkinsonism were the most common movement disorder and chorea was the least common. Magnetic resonance imaging of brain was performed in all and basal ganglia abnormality and cortical ribboning was seen in more than two-third of cases. Electroencephalographic abnormality was noted in 21 patients with triphasic waves and periodic sharp waves seen in 7 and 6 patients respectively. Cerebrospinal fluid 14-3-3 assay was abnormal in 2 out of 4 patients. Atypical presentations were noted in the form of ataxic presentation, CBS like presentation and choreiform presentation. Myoclonus, ataxia and parkinsonism are the most frequent movement disorders phenomenology observed in patients with sCJD.

Temporal dynamics of triphasic waves and generalized periodic discharges (P10-1.012)

<h3>Objective:</h3> To quantitatively compare triphasic waves and generalized periodic discharges on scalp EEG. <h3>Background:</h3> Distinguishing epileptiform generalized periodic discharges (GPDs) and triphasic waves (TWs) can be challenging (Foreman <i>et al.</i>, 2016), and consequential since groups may benefit from anti-seizure medications differently. Discharge regularity is an important feature recapitulated in computational models of TWs (Song <i>et al.</i>, 2019) and GPDs (Ruijter <i>et al.</i>, 2017). Recent analysis of GPDs in patients after cardiac arrest have shown that regularity of GPD duration, morphology, and amplitude, based on visual scoring, portend worse prognoses (Nadjar <i>et al.</i>, 2022). This suggests that variability of discharges could be a quantifiable tool in distinguishing GPDs from TWs. <h3>Design/Methods:</h3> We retrospectively collected inpatient EEG recordings marked to show GPDs and TWs from Harborview Medical Center between 11/2020 and 5/2021. The best derivation of a 30 second artifact free period on average reference montage was low pass filtered (0–15hz) for analysis. After visually identifying discharges, interdischarge intervals (IDIs) were calculated based on maximal deflection of each discharge. For each EEG, variance of IDIs was normalized by median IDI, to calculate a regularity index (RI). RI of GPDs and TWs were compared with a one-tailed Wilcoxon rank sum test. <h3>Results:</h3> 24 EEGs with TWs and 33 EEGs with GPDs were studied. Median RI for TWs was 0.438 with a variance of 3.08. Median RI for GPDs was 0.368 with a variance of 4.31. Groups were not statistically different (<i>p</i>=0.08). Excluding EEGs of following cardiac arrest, 23 EEGs with TWs and 10 EEGs with GPDs were studied. Median RI of TWs was 0.430 with variance of 3.14. Median RI of GPDs was 3.14 with variance of 13.7. Groups were not statistically different (<i>p</i>=0.27). <h3>Conclusions:</h3> Comparison of normalized variability in IDI does not distinguish TWs from GPDs but may have utility in the context of other clinical data. <b>Disclosure:</b> Dr. Plummer has nothing to disclose. Dr. Raut has nothing to disclose. Dr. Brunton has received personal compensation for serving as an employee of University of Washington. The institution of Dr. Brunton has received research support from National Science Foundation . The institution of Dr. Brunton has received research support from Air Force Office of Scientific Research. The institution of Dr. Brunton has received research support from National Science Foundation. Dr. Hakimian has received personal compensation in the range of $500-$4,999 for serving as a Consultant for OptumRx. Dr. Hakimian has stock in Various.

Clinical and Electrographic Features in Beta-Lactam Antibiotic Induced Neurotoxicity (P3-1.012)

<h3>Objective:</h3> To characterize clinical and electrographic features of patients with beta-lactam antibiotic-induced neurotoxicity in presence of and without renal impairment (RI). <h3>Background:</h3> EEG findings like periodic discharges, triphasic waves, or status epilepticus have been associated with beta-lactam neurotoxicity in critically ill patients with renal impairment. <h3>Design/Methods:</h3> Medical records of patients undergoing EEG due to encephalopathy while receiving cefepime, cefazoline and meropenem at the KUMC from 2009–2018 were reviewed. Demographic data, creatinine levels, clinical information, electrographic findings, and AEDs used were obtained. Exclusion criteria included unknown antibiotic start date, no clinical changes after antibiotic onset, worsening unrelated to antibiotics, or mental improvement on antibiotics. Patients were divided into with and without RI. Descriptive statistical methods and Chi-square/Fisher’s exact tests were applied. <h3>Results:</h3> 196 patients were identified. After applying our exclusion criteria, 39 patients were included, of which 14 (36%) were males and 25 (64%) were females. Thirty-three patients (85%) were on cefepime. Further analysis was focused on cefepime only since the number of patients on other antibiotics was nonsignificant. Symptoms reported were altered mental status (64%) [43% had RI], myoclonus (15%) [100% had RI] and seizures (9%) [67% had RI]. A tendency to have myoclonus was seen in patients with RI (p=0.049). EEG findings were generalized slowing (91%), triphasic waves (56%), GPDs (42%), and LPDs (12%). Six patients were found with NCSE, of which 4 (67%) had RI (p=0.490). Twenty-four (73%) patients symptomatically improved after stopping cefepime. Improvements in EEG were seen in 14 out of 22 patients who had repeat EEGs or were followed with EEG monitoring. <h3>Conclusions:</h3> Seizures were infrequently seen in patients with beta-lactam neurotoxicity. Removal of offending agents can improve clinical outcomes and prognosis in cefepime induced neurotoxicity. <b>Disclosure:</b> Dr. Ortiz Guerrero has nothing to disclose. Dr. Shah has nothing to disclose. Dr. Uysal has nothing to disclose.

Lithium neurotoxicity – a case report and review of the literature

IntroductionLithium, a mood stabilizer, is a commonly prescribed and effective treatment for bipolar affective disorder. It´s excreted almost exclusively by the kidneys with a half-life primarily determined by renal function. Chronic intoxication results from an insidious accumulation of lithium in a chronically medicated patient (due to a reduction in renal function secondary to volume depletion, a new medication, et cetera). Patients often present with neurologic findings, including tremor, ataxia, dysarthria, confusion and neuromuscular excitability.ObjectivesThe objective of this report is to describe a clinical case of lithium neurotoxicity (myoclonus and encephalopathy), along with a review of the literature on the topic.MethodsWe describe a case of lithium neurotoxicity, along with a brief non-systematic review of the literature on lithium toxicity. We conducted a PubMed bibliographic search using keywords such as “lithium intoxication”, “lithium neurotoxicity”, “lithium encephalopathy” and “lithium intoxication treatment”.ResultsA women aged 81 was brought to the emergency department by her daughter following 1 week of asthenia, diarrhoea, periods of confused speech and involuntary movements. In the previous week, the patient had been diagnosed with COVID-19. Her past medical history is significant for bipolar affective disorder, hypertension, diabetes mellitus, dyslipidemia and asthma. The patient has been treated with following drugs: lithium carbonate (no recent change of dose and previous serum levels around 1mmol/L), quetiapine, lisinopril, metformin, simvastatin, formoterol and budesonide. On the first examination, she had an exuberant multifocal myoclonus. Posteriorly, she became somnolent, with language impairment (verbal perseveration, echolalia) and dysarthria. Investigations revealed renal impairment (creatinine 1,5 mg/dL, blood urea nitrogen 42 mg/dL) and supratherapeutic lithium levels (lithium serum level 1,7 mmol/L). Computed tomography scan of the brain was negative for acute injuries. The electroencephalogram showed triphasic waves (1-1,5 Hz). Encephalopathy secondary to lithium intoxication was diagnosed (probably in the context of acute kidney injury precipitated by hypovolaemia – diarrhoea). Lithium was stopped and intravenous isotonic fluids were given. After 1 week, her myoclonus resolved and over the following week the other signs resolved as well. The patient was later discharged to her daughter’s home, with follow-up neurology and psychiatry visits.ConclusionsBoth reversible and irreversible neurotoxicity related to lithium have been reported, specially occurring alongside chronic intoxication. If not addressed, impaired consciousness can lead to coma and death. A high clinical suspicion is needed for prompt diagnosis and treatment (intravenous fluids and sometimes haemodialysis are warranted).Disclosure of InterestNone Declared

Reversible Burst-suppression Pattern of Acute Hyperammonemic Encephalopathy

Acute hyperammonemic encephalopathy is generally associated with severe liver disease, manifesting with neuropsychiatric symptoms including confusion, lethargy, seizure, coma, and even death. Electroencephalogram (EEG) is a proven diagnostic, prognostic, and therapeutic tool in patients with acute and chronic encephalopathies. EEG changes in acute hyperammonemic encephalopathy are associated with background slowing in theta to delta ranges, accompanied by presence of triphasic waves. We reported a patient with acute hyperammonemic encephalopathy showing an unusual burst-suppression pattern, which was reversible with proper treatment.

587 - Triphasic waves with exceptional response to diazepam

587 - Triphasic waves with exceptional response to diazepam

Valproate-Induced Nonhyperammonemic Encephalopathy with Electroencephalogram Background Slowing and Triphasic Waves

Valproate-Induced Nonhyperammonemic Encephalopathy with Electroencephalogram Background Slowing and Triphasic Waves

Continuous EEG monitoring detects nonconvulsive seizure and Ictal-Interictal Continuum abnormalities in moderate to severe ICANS following systemic CAR-T therapy.

Immune Cell Effector Associated Neurotoxicity Syndrome (ICANS) is common amongst patients receiving CD19 targeted Chimeric Antigen Receptor T-cell (CAR-T) therapy. The purpose of this study is to characterize the incidence of seizures and ictal-interictal continuum (IIC) abnormalities in patients with ICANS. Retrospective review of consecutive patients treated with axicabtagene ciloleucel (axi-cel) for recurrent high-grade systemic lymphoma at Stanford Medical Center between 2/2016-6/2019. Electronic medical records (EMR) were reviewed for clinical features, treatment information, EEG data, CRS (cytokine release syndrome)/ICANS severity, and clinical outcomes. Fifty-six patients met inclusion criteria. 85.7% of patients developed CRS, and 58.9% developed ICANS. Twenty-eight patients had EEG monitoring, of whom 26 had ICANS. Median duration of EEG monitoring was 30 hours (range .5-126 hours). Four patients (7.1%) had seizures (1 patient had a clinical generalized seizure, 2 patients had clinical and nonconvulsive seizures, and 1 patient had an isolated non-convulsive seizure). Ictal-interictal continuum abnormalities were common, of which generalized periodic discharges (GPDs) with triphasic morphology and GPDs with epileptiform morphology were most frequently seen. Generalized periodic discharges with triphasic wave morphology were found across Grade 2-3 peak ICANS severity, however the majority (86%) of patients with epileptiform GPDs had Grade 3 peak ICANS severity. Among patients receiving axi-cel, seizure occurred in 7.1% of the total cohort, representing 12% of patients with ICANS. Ictal-interictal continuum abnormalities are also seen in patients with ICANS, most commonly GPDs. 75% of patients with seizures had nonconvulsive seizures supporting the use of continuous video EEG monitoring in this population.

New Onset Encephalopathy with Toxic Triphasic Waves

AbstractNew onset encephalopathy can have various causes like stroke, trauma, seizures, infections, demyelination, neoplasms, autoimmune, degenerative, and toxic and metabolic etiologies. Triphasic waves in electroencephalogram (EEG) is usually a clue to an ongoing metabolic process. We report a case of a 69-year-old female with bipolar disorder who presented with altered sensorium for the last 2 days. Her metabolic parameters, imaging, and cerebrospinal fluid findings were normal. Her EEG findings in the clinical setting provided a diagnostic clue to lithium toxicity, even though her serum lithium levels were normal. As her sensorium was progressively worsening, she was given a trial of hemodialysis with which she had significant improvement.

CARBAMAZEPINE-ASSOCIATED HYPERAMMONEMIC ENCEPHALOPATHY (HE)

CARBAMAZEPINE-ASSOCIATED HYPERAMMONEMIC ENCEPHALOPATHY (HE)

Doppler ultrasonography is a useful tool for the diagnosis of hemodynamics in congestive graft injury due to heart failure after liver transplantation: A case report

IntroductionPatients with end-stage liver disease often have cardiac dysfunction, which can be worsened by hemodynamic instability in liver transplantation, causing congestive graft injury.Presentation of caseA 28-year-old male with Wilson's disease underwent liver transplantation. The patient's history included cirrhotic cardiomyopathy and a preoperative ejection fraction of 37% on echocardiography. After liver transplantation, massive transfusion and acute renal failure led to increased central venous pressure. Doppler ultrasonography (US) showed an increase in positive components of the hepatic vein triphasic wave, followed by pulsatile changes in the portal vein waveforms and an eventual to-and-fro pattern. Laboratory data showed severe elevations of hepatocellular transaminase levels. Based on Doppler US findings, we determined liver damage was due to passive congestion caused by heart failure. Immediate initiation of continuous hemodiafiltration (CHDF) and intra-aortic balloon pumping (IABP) led to the patient's recovery from severe heart failure and graft injury.DiscussionIn our case, changes in the hepatic and portal vein waveforms and marked elevation of hepatocellular transaminases implied exacerbation of heart failure caused by hepatic congestion and injury. Worsening heart failure, in turn, led to progressive liver damage as the result of hepatic passive congestion. The patient's condition was successfully managed with early initiation of CHDF and IABP.ConclusionDoppler US can help diagnose congestive graft injury due to heart failure in liver transplant patients and should be performed during post-transplant management of patients with cardiac dysfunction.

WS1.12. EEG Coma Patterns and Prognosis

Identify the EEG coma patterns is just one of the steps in clinical management of those with coma. This lecture will discuss on the importance of EEG in diagnosis, prognosis, management and monitoring of disease progress, but also the limitations of EEG. There are various EEG patterns in coma including both focal and generalised EEG patterns. It is essential to correlate the EEG with clinical findings, in order to determine the aetiology, although in certain cases the EEG patterns will guide the diagnosis e.g. triphasic waves in metabolic encephalopathy and periodic discharges in someone suspected to have Creutzfeldt- Jakob disease. A clinical-based approach to differentiate epileptiform and non-epileptiform patterns will be presented based on clinical history, EEG patterns, neuroimaging and response to antiepileptic drugs. An attempt to determine the severity and prognosis based on EEG patterns will be made, in correlation with the underlying aetiology and other clinical findings. Lastly, EEG patterns in coma secondary to autoimmune encephalopathy will be discussed.