Teleradiology-based stroke network in Western and Southern Transdanubia in Hungary / Stroke-ellátást támogató teleradiológiai hálózat a Nyugat- és Dél-Dunántúlon.

Összefoglaló. Bevezetés: A stroke kezelésének lehetoségei az utóbbi években jelentosen megváltoztak: a thrombolysis után bevezetésre került a mechanikus thrombectomia, és a terápiás idoablak is jelentosen kitágult az utóbbi évek nagy multicentrikus tanulmányai alapján. Ezek a lehetoségek új igényeket fogalmaztak meg a képalkotó diagnosztikával szemben: az ischaemia okozta morfológiai elváltozások mellett az artériás és a kollaterális rendszer állapotát, valamint bizonyos esetekben az agy szöveti perfúzióját is szükséges meghatározni. Ezeket a komplex kiértékelési feladatokat ma már mesterségesintelligencia-algoritmusok támogathatják, melyek a kiértékelést pár perc alatt elvégezve segítenek a terápiás döntés kialakításában. Célkituzés: A Dél- és a Nyugat-dunántúli régióban hat intézmény részvételével egy dedikált stroke teleradiológiai hálózat kialakítása. Módszer: A stroke-CT-kiértékelo szoftver és a képkommunikáció integrációja, a vizsgálati protokollok technikai paramétereinek egységesítése, a kiértékelési eredmények teleradiológiai megjelenítése valósult meg a hálózat kialakítása során. Eredmények: A hálózat egységesítette nemcsak a stroke-CT-protokollok beállításait, de beutalási és értékelési szempontjait is. A stroke-CT-kiértékelések és a mechanikus thrombectomiák száma is emelkedett az elmúlt egy évben. Következtetés: A dedikált teleradiológiai stroke-hálózat segítségével optimalizálni kívánjuk a régió stroke-ellátását: egyrészt lehetoleg ne maradjanak ellátatlanul a thrombectomiából valószínuleg profitáló betegek, másrészt ne terheljük az ellátórendszert olyan esetekkel, melyekrol a teljes dokumentáció ismeretében derül ki, hogy nem javasolt a beavatkozás. Orv Hetil. 2021; 162(17): 668-675. INTRODUCTION: The possibilities of cerebral stroke management have changed substantially during the last few years. Following a few multicentric studies, mechanical thrombectomy became an established method besides thrombolysis. In addition, the therapeutic window for both methods is much wider now than before. These changes described above demanded more information of CT morphological changes due to ischemia, but the condition and functionality of the arterial and collateral system, and occasionally tissue perfusion performance should also be characterized. Recently, evaluation of different computer tomographic (CT) measurements can be done using artificial intelligence based methods, which perform data analysis in a few minutes. OBJECTIVE: To establish a dedicated stroke teleradiology network with artificial intelligence based image analysis in Western and Southern Transdanubia in Hungary that involves six partner institutes. METHOD: Integration of automated image analysis with teleradiology software was established, and the technical parameters of examination protocols were unified. Results of stroke CT image analysis became accessible through the teleradiology network. RESULTS: The daily use of integrated central image analysis and image communication had a positive impact on referrals and therapeutic evaluation of stroke cases. The number of image processing and mechanical thrombectomy increased during the last year. CONCLUSION: With the help of the dedicated teleradiology stroke network, we want to optimize the stroke care in the region: on the one hand, patients who are likely to benefit from thrombectomy should not be left unattended, on the other, the health care system should not be burdened with cases, when intervention is not recommended having the complete clinical data accessed. Orv Hetil. 2021; 162(17): 668-675.

Utilization of acute vascular imaging and neurointervention for acute ischaemic stroke patients in 20 Hungarian stroke centers.

BACKGROUND AND PURPOSE: Acute mortality rate of stroke in Hungary is significantly higher than in Western Europe, which is likely to be partially attributable to suboptimal treatment. METHODS: We examined the use of acute vascular imaging and mechanical thrombectomy for acute ischaemic stroke patients. We collected data on 20 consecutive patients from Hungarian stroke centers before 31st August 2016. RESULTS: Out of the reported 410 patients, 166 (40.4%) underwent CT angiography and 44 (10.7%) had mechanical thrombectomy. CONCLUSION: Only about 1/3 of acute ischaemic stroke patients eligible for thrombectomy actually had it. The underlying reasons include long onset-to-door time, low utilization of acute vessel imaging and a limited neuro-intervention capacity needing improvement.

Differences of brain electrical activity between moderate and severe obstructive sleep apneic patients: a LORETA study.

The effects of initiation of continuous positive airway pressure (CPAP) therapy on electroencephalographic (EEG) background activity were investigated in patients exhibiting both moderate (n = 13) and severe (n = 12) obstructive sleep apnea syndromes in the testing of the potential differences of alterations of brain electrical activity caused by chronic hypoxia between these two groups. A normal control group (n = 14) was also examined. Two EEG examinations were achieved in each group: before and after first-time CPAP therapy. Low-resolution electromagnetic tomography (LORETA) was implemented towards localizing the generators of EEG activity in separate frequency bands. Prior to CPAP treatment, as a common direction of change, analysis with LORETA demonstrated increased activity in comparison with the patient and control groups. In the moderate group, significant changes were detected in the alpha2 band in the posterior cingulate cortex as well as in the beta1 band in the right posterior parietal cortex and the left supramarginal gyrus. In the severe group, significant changes were found in theta and alpha1 bands in the posterior cingulate cortex. Following CPAP treatment, these significant differences vanished in the severe group. In the moderate group, significantly decreased activity was seen in the beta3 band in the right fusiform gyrus. These findings potentially suggest a normalizing effect of CPAP therapy on EEG background activity in both groups of obstructive sleep apnea syndrome patients. Compensatory alterations of brain electrical activity in regions associated with influencing successful memory retrieval, emotional perception, default mode network, anorexia and fear network caused by chronic intermittent hypoxia could possibly be reversed with the use of CPAP therapy.

[INDIVIDUAL EVALUATION OF LORETA ABNORMALITIES IN IDIOPATHIC GENERALIZED EPILEPSY]. / EGYEDI LORETA-ABNORMALITÁSOK VIZSGÁLATA IDIOPATHIÁS GENERALIZÁLT EPILEPSZIÁKBAN.

BACKGROUND: Contemporary neuroimaging methods disclosed structural and functional cerebral abnormalities in idiopathic generalized epilepsies (IGEs). However, individual electrical (EEG) abnormalities have not been evaluated yet in IGE patients. METHODS: IGE patients were investigated in the drug-free condition and after 3-6 month of antiepileptic treatment. To estimate the reproducibility of qEEG variables a retrospective recruited cohort of IGE patients was investigated. 19-channel resting state EEG activity was recorded. For each patient a total of 2 minutes EEG activity was analyzed by LORETA (Low Resolution Electromagnetic Tomography). Raw LORETA values were Z-transformed and projected to a MRI template. Z-values outside within the [+3Z] to [-3Z] range were labelled as statistically abnormal. RESULTS: 1. In drug-free condition, 41-50% of IGE patients showed abnormal LORETA values. 2. Abnormal LORETA findings showed great inter-individual variability. 3. Most abnormal LORETA-findings were symmetrical. 4. Most maximum Z-values were localized to frontal or temporal cortex. 5. Succesfull treatment was mostly coupled with disappearence of LORETA-abnormality, persistent seizures were accompanied by persistent LORETA abnormality. DISCUSSION: 1. LORETA abnormalities detected in the untreated condition reflect seizure-generating property of the cortex in IGE patients. 2. Maximum LORETA-Z abnormalities were topographically congruent with structural abnormalities reported by other research groups. 3. LORETA might help to investigate drug effects at the whole-brain level.

Effects of CPAP-therapy on brain electrical activity in obstructive sleep apneic patients: a combined EEG study using LORETA and Omega complexity : reversible alterations of brain activity in OSAS.

Effects of initiation of continuous positive airway pressure (CPAP) therapy on EEG background activity were investigated in patients with obstructive sleep apnea syndrome (OSAS, N = 25) to test possible reversibility of alterations of brain electrical activity caused by chronic hypoxia. Normal control group (N = 14) was also examined. Two EEG examinations were done in each groups: at night and in the next morning. Global and regional (left vs. right, anterior vs. posterior) measures of spatial complexity (Omega complexity) were used to characterize the degree of spatial synchrony of EEG. Low resolution electromagnetic tomography (LORETA) was used to localize generators of EEG activity in separate frequency bands. Before CPAP-treatment, a significantly lower Omega complexity was found globally and over the right hemisphere. Due to CPAP-treatment, these significant differences vanished. Significantly decreased Omega complexity was found in the anterior region after treatment. LORETA showed a decreased activity in all of the beta bands after therapy in the right hippocampus, premotor and temporo-parietal cortex, and bilaterally in the precuneus, paracentral and posterior cingulate cortex. No significant changes were seen in control group. Comparing controls and patients before sleep, an increased alpha2 band activity was seen bilaterally in the precuneus, paracentral and posterior cingulate cortex, while in the morning an increased beta3 band activity in the left precentral and bilateral premotor cortex and a decreased delta band activity in the right temporo-parietal cortex and insula were observed. These findings indicate that effect of sleep on EEG background activity is different in OSAS patients and normal controls. In OSAS patients, significant changes lead to a more normal EEG after a night under CPAP-treatment. Compensatory alterations of brain electrical activity in regions associated with influencing sympathetic outflow, visuospatial abilities, long-term memory and motor performances caused by chronic hypoxia could be reversed by CPAP-therapy.

Characteristic changes in brain electrical activity due to chronic hypoxia in patients with obstructive sleep apnea syndrome (OSAS): a combined EEG study using LORETA and omega complexity.

EEG background activity of patients with obstructive sleep apnea syndrome (OSAS, N = 25) was compared to that of normal controls (N = 14) to reflect alterations of brain electrical activity caused by chronic intermittent hypoxia in OSAS. Global and regional (left vs. right, anterior vs. posterior) measures of spatial complexity (Omega) were used to characterize the degree of spatial synchrony of EEG. Low resolution electromagnetic tomography (LORETA) was used to localize generators of EEG activity in separate frequency bands. Comparing patients to controls, lower Omega complexity was found globally and in the right hemisphere. Using LORETA, an increased medium frequency activity was seen bilaterally in the precuneus, paracentral and posterior cingulate cortex. These findings indicate that alterations caused by chronic hypoxia in brain electrical activity in regions associated with influencing emotional regulation, long-term memory and the default mode network. Global synchronization (lower Omega complexity) may indicate a significantly reduced number of relatively independent, parallel neural processes due to chronic global hypoxic state in apneic patients as well as over the right hemisphere.

Three-dimensional localization of abnormal EEG activity in migraine: a low resolution electromagnetic tomography (LORETA) study of migraine patients in the pain-free interval.

Investigating the brain of migraine patients in the pain-free interval may shed light on the basic cerebral abnormality of migraine, in other words, the liability of the brain to generate migraine attacks from time to time. Twenty unmedicated "migraine without aura" patients and a matched group of healthy controls were investigated in this explorative study. 19-channel EEG was recorded against the linked ears reference and was on-line digitized. 60 x 2-s epochs of eyes-closed, waking-relaxed activity were subjected to spectral analysis and a source localization method, low resolution electromagnetic tomography (LORETA). Absolute power was computed for 19 electrodes and four frequency bands (delta: 1.5-3.5 Hz, theta: 4.0-7.5 Hz, alpha: 8.0-12.5 Hz, beta: 13.0-25.0 Hz). LORETA "activity" (=current source density, ampers/meters squared) was computed for 2394 voxels and the above specified frequency bands. Group comparison was carried out for the specified quantitative EEG variables. Activity in the two groups was compared on a voxel-by-voxel basis for each frequency band. Statistically significant (uncorrected P < 0.01) group differences were projected to cortical anatomy. Spectral findings: there was a tendency for more alpha power in the migraine that in the control group in all but two (F4, C3) derivations. However, statistically significant (P < 0.01, Bonferroni-corrected) spectral difference was only found in the right occipital region. The main LORETA-finding was that voxels with P < 0.01 differences were crowded in anatomically contiguous cortical areas. Increased alpha activity was found in a cortical area including part of the precuneus, and the posterior part of the middle temporal gyrus in the right hemisphere. Decreased alpha activity was found bilaterally in medial parts of the frontal cortex including the anterior cingulate and the superior and medial frontal gyri. Neither spectral analysis, nor LORETA revealed statistically significant differences in the delta, theta, and beta bands. LORETA revealed the anatomical distribution of the cortical sources (generators) of the EEG abnormalities in migraine. The findings characterize the state of the cerebral cortex in the pain-free interval and might be suitable for planning forthcoming investigations.

Imaging the cortical effect of lamotrigine in patients with idiopathic generalized epilepsy: a low-resolution electromagnetic tomography (LORETA) study.

PURPOSE: Anatomical localization of the cortical effect of lamotrigine (LTG) in patients with idiopathic generalized epilepsy (IGE). METHODS: 19 patients with untreated IGE were investigated. EEG was recorded in the untreated condition and 3 months later when LTG treatment abolished the seizures. 19-channel EEG was recorded, and a total of 2min artifact-free, waking EEG was processed to low-resolution electromagnetic tomography (LORETA) analysis. Activity (that is, current source density, A/m(2)) was computed in four frequency bands (delta, theta, alpha, and beta), for 2394 voxels that represented the cortical gray matter and the hippocampi. Group differences between the untreated and treated conditions were computed for the four bands and all voxels by multiple t-tests for interdependent datasets. The results were presented in terms of anatomical distribution and statistical significance. RESULTS: p<0.01 (uncorrected) changes (decrease of activity) emerged in the theta and the alpha bands. Theta activity decreased in a large cluster of voxels including parts of the temporal, parietal, occipital cortex bilaterally, and in the transverse temporal gyri, insula, hippocampus, and uncus on the right side. Alpha activity decreased in a relatively smaller cortical area involving the right temporo-parietal junction and surrounding parts of the cortex, and part of the insula on the right side. CONCLUSIONS: LTG decreased theta activity in several cortical areas where abnormally increased theta activity had been found in a prior study in another cohort of untreated IGE patients [Clemens, B., Bessenyei, M., Piros, P., Tóth, M., Seress, L., Kondákor, I., 2007b. Characteristic distribution of interictal brain electrical activity in idiopathic generalized epilepsy. Epilepsia 48, 941-949]. These LTG-related changes might be related to the decrease of seizure propensity in IGE.

Spectral characteristics and linear-nonlinear synchronization changes of different EEG frequency bands during the CNV.

During the CNV recorded in a simple auditory working memory task, task-specific decrease of the relative delta band and a transient increase of the absolute theta band were seen, accompanied by an increase of the absolute alpha1 and alpha2 bands in the posterior region. The decreased delta power probably corresponds to increased task-evoked arousal, whereas the transient theta power increase corresponds to working memory demand and possibly to the orienting response. The increased alpha1 and alpha2 power may be a manifestation of a top-down mechanism revealing control over the execution of a response. The area-specific, task-related, and frequency-dependent changes of EEG complexity measures indicate frontally increasing complexity during the early part of the CNV in the beta frequency bands, which underscores the importance of this region in the mechanisms of anticipatory behavior.

Diurnal alterations of brain electrical activity in healthy adults: a LORETA study.

EEG background activity was investigated by low resolution brain electromagnetic tomography (LORETA) to test the diurnal alterations of brain electrical activity in healthy adults. Fourteen right-handed healthy male postgraduate medical students were examined four times (8 a.m., 2 p.m., 8 p.m. and next day 2 p.m.). LORETA was computed to localize generators of EEG frequency components. Comparing the EEG activity between 2 p.m. and 8 a.m., increased activity was seen (1) in theta band (6.5-8 Hz) in the left prefrontal, bilateral mesial frontal and anterior cingulate cortex; (2) in alpha2 band (10.5-12 Hz) in the bilateral precuneus and posterior parietal cortex as well as in the right temporo-occipital cortex; (3) in beta1-2-3 band (12.5-30 Hz) in the right hippocampus and parieto-occipital cortex, left frontal and bilateral cingulate cortex. Comparing the brain activity between 8 p.m. and 8 a.m., (1) midline theta activity disappeared; (2) increased alpha2 band activity was seen in the left hemisphere (including the left hippocampus); and (3) increased beta bands activity was found over almost the whole cortex (including both of hippocampi) with the exception of left temporo-occipital region. There were no significant changes between the background activities of 2 p.m. and next day 2 p.m. Characteristic distribution of increased activity of cortex (no change in delta band, and massive changes in the upper frequency bands) may mirror increasing activation of reticular formation and thus evoked thalamocortical feedback mechanisms as a sign of maintenance of arousal.

Characteristic distribution of interictal brain electrical activity in idiopathic generalized epilepsy.

PURPOSE: To demonstrate the anatomic localization of the cortical sources of the interictal EEG activity in human idiopathic generalized epilepsy (IGE). METHODS: Multiple cortical and hippocampal sources of the interictal spontaneous EEG activity were investigated by low-resolution electromagnetic tomography in 15 untreated IGE patients and in 15 healthy controls. EEG activity (current density) in four frequency bands (delta: 1.5-3.5 Hz, theta: 3.5-7.5 Hz, alpha: 7.5-12.5 Hz, beta: 12.5-25.0 Hz) was computed for 2,397 voxels. Voxel-by-voxel group comparison was done between the patient and the control group. Voxels with p < 0.01 differences (between the two groups) were correlated with cortical anatomy. RESULTS: Areas of significantly increased or decreased activity were characterized by their anatomical extension and the frequency bands involved. Five areas of bilaterally increased activity were found: rostral part of the prefrontal cortex (delta, theta); posterior part of the insula (delta); hippocampus and mediobasal temporal cortex (all frequency bands); medial parietooccipital cortex (theta, alpha, beta); dorsal and polar parts of the occipital cortex (alpha). Bilaterally decreased delta, theta, alpha activity was found in the majority of the frontal and anterior parietal cortex on the lateral surface, and in parts of the medial surface of the hemispheres. The area of decreased beta activity was less extensive. The right lateral and laterobasal temporal cortex showed decreased delta, theta, alpha, and beta activity, while its left counterpart only showed decreased delta and alpha activity in a limited part of this area. CONCLUSIONS: (1) Pathological interictal EEG activity is not evenly distributed across the cortex in IGE. The prefrontal area of increased activity corresponds to the area that is essential in the buildup of the ictal spike-wave paroxysms (absence seizures). The existence of the posterior "center of gravity" of increased EEG activity in IGE was confirmed. The frontal area of decreased activity might be related to the cognitive deficit described in IGE patients. (2) Increased activity in a lot of ontogenetically older areas (including the hippocampi) and decreased activity in the majority of the isocortex is a peculiar pattern that argues for a developmental hypothesis for IGE.

Distribution of spatial complexity of EEG in idiopathic generalized epilepsy and its change after chronic valproate therapy.

The objective of this study was to investigate the global and regional spatial synchrony of the EEG background activity, and to assess the effect of chronic valproate therapy on spatial synchrony. 15 idiopathic generalized epilepsy (IGE) patients were examined and compared to 16 normal controls. Resting EEG with 19 channels was investigated before and during chronic administration of valproate (VPA). Omega, a single-valued measure of spatial covariance complexity, was calculated to assess the degree of spatial synchrony of EEG. Furthermore, a new parameter was defined to characterize the distribution of spatial synchrony (Antero-Posterior Complexity Ratio, APCR). Global Omega complexity was significantly lower in IGE compared to controls, while regional complexity showed significant differences only in the anterior region: the IGE group showed lower complexity. APCR was significantly lower in IGE. VPA therapy (1) lowered the global complexity, (2) increased regional complexity in the anterior region, but decreased it in the posterior region, and (3) increased APCR. In IGE lower complexity, i.e. enhanced spatial synchrony, was found, especially in the anterior cortical area. VPA modified the distribution of spatial synchrony in IGE patients towards that of normal controls, although the effect is not identical with full normalization of cortical bioelectric activity. Whether the observed change of spatial synchrony distribution may reflect the normalizing effect of valproate on the brain state is worth further investigation.

Effects of sweet and bitter gustatory stimuli in anorexia nervosa on EEG frequency spectra.

The possible differences in processing gustatory stimuli in anorexic patients compared to healthy control subjects was investigated by electrophysiological methods. The electroencephalogram (EEG) was recorded in outpatients treated with anorexia nervosa (AN) and age-matched controls after exposure to sweet (milk chocolate) and bitter (black tea) taste stimuli. Power spectrum analysis was performed on EEG epochs recorded in the above conditions. Compared to controls a significantly higher percent of theta, and lower percent of alpha1 band power was found in anorexic patients, irrespective of the kind of taste effects and hemispheric side. The pattern of activation caused by sweet and bitter stimuli was found to be different in these two groups, possibly indicating altered gustatory processing mechanisms in AN.

Nonlinear and linear EEG complexity changes caused by gustatory stimuli in anorexia nervosa.

The objective of the present study was to investigate the effects of pleasant and unpleasant gustatory stimuli on nonlinear and linear complexity measures of the EEG in healthy controls and in anorexia nervosa (AN) patients. The subjects were exposed to unpleasant (bitter tea) and pleasant (chocolate) gustatory stimuli for 2 min. Multichannel EEG was recorded and the dimensional complexity (point-correlation dimension) and Omega complexity were calculated from the EEG epochs corresponding to the above taste conditions. In AN patients lower-dimensional complexity was observed in the majority of recording sites than that seen in controls, independent of taste conditions. Higher Omega complexity was seen in control subjects in the left side irrespective of taste effects. No such hemispheric difference was observed in AN. The lower-dimensional complexity seen in AN patients may be caused by long-lasting effects of malnutrition. The lack of a significant Omega complexity change in response to exposure of sweet taste in the left side seen in AN patients may correspond to a decreased sensitivity to such stimuli in these subjects.

[Effects of piracetam on the cognitive functions verified by electrophysiologic methods]. / A piracetam kognitív funkciókra gyakorolt hatásainak vizsgálata elektrofiziológiai módszerekkel.

The well-known psychoactive drug widely used in the daily clinical praxis, the piracetam has many therapeutical indications. The drug is extensively applied in the therapy of ischaemic stroke, aphasy as well as of dementias of several origins and age-depending cognitive disturbances. One of the most important effect of piracetam is the positive effect to the cognitive functions. In this publication the author reviews the most important studies, where significant effects of piracetam (chronic or single-dose treatment) were verified by means of electrophysiological methods. These studies proved objectively the positive psychoactive and cognitive effects of the drug, supporting the therapeutical indication of piracetam in such cases, where cognitive deficits are present.