Perampanel as only add-on epilepsy treatment in elderly: A subgroup analysis of real-world data from retrospective, multicenter, observational study.

INTRODUCTION: Drug management of epilepsy in the elderly presents unique but data on this population are scarce. This study aimed to assess the effectiveness and tolerability of perampanel (PER) used as only add-on to a background anti-seizure medication (ASM) in the elderly in a real-world setting. METHODS: We performed a subgroup analysis of patients aged ≥65 years included in a previous 12-month multicenter study on adults. Treatment discontinuation, seizure frequency, and adverse events were recorded at 3, 6 and 12 months after PER introduction. Sub-analyses by early (≤1 previous ASM) or late PER add-on were also conducted. RESULTS: The sample included 65 subjects (mean age: 75.7 ± 7.2 years), with mainly focal (73.8%) epilepsy. The mean PER daily dose was ≈4 mg during all follow-up. Retention rates at 3, 6, and 12 months were 90.5%, 89.6%, and 79.4%ly. The baseline median normalized per 28-day seizure number significantly decreased at 3-, 6- and 12-month visits. One year after PER introduction, the responder rate (≥50% reduction in baseline seizure frequency) was 89.7%, with a seizure freedom rate of 72.4%. Adverse events occurred in 22 (34.9%) patients with dizziness and irritability being the most frequent. No major differences between early (41 patients, 63.1%), and late add-on groups were observed. CONCLUSION: Adjunctive PER was effective and well-tolerated when used as only add-on treatment in elderly people with epilepsy in clinical practice, thus representing a suitable therapeutic option in this age category.

Emotional arousal and valence in patients with fibromyalgia: a pilot study.

The pathogenesis of pain in fibromyalgia is still not completely understood. A disrupted emotional modulation could affect the physiology of nociception and contributes to an altered perception of pain. The aim of this study was to test the role of emotional arousal and valence in pain susceptibility in fibromyalgia using the International Affective Picture System (IAPS) paradigm and the Fibromyalgia Severity Scale (FSS). The study focused on comparing emotional arousal and valence between patients with fibromyalgia and the control group. The secondary objective was to examine the correlation between emotional indices and scores on the FSS and the duration of the disease. The 20 patients with fibromyalgia enrolled showed a higher mean arousal score for all the stimuli, including a higher score for unpleasant and socially unpleasant stimuli. The valence scores for social-relevant stimuli were also higher. Increased arousal to unpleasant and socially unpleasant images and increased valence of them correlated with the duration of the disease and the severity of symptoms and could reflect impairment in social cognition and marked sensitivity to pain in interaction with central nociceptive dysregulation.

The stress response of intensive care unit medical doctors facing repeated severe emergencies.

Objectives: This study assesses the psychopathological distress experienced by doctors working in an Intensive care unit (ICU) during the COVID-19 pandemic. These doctors were the same who faced the consequences of a previous natural disaster, a severe 6.3 magnitude earthquake. A second objective is to evaluate their current mental attitude, professional performances and coping strategies adopted in the pandemic in relation to the conditioning effect of that first emergency, the earthquake. Methods: Thirty-seven ICU medical doctors were recruited and assessed using Rapid Stress Assessment (RSA) rating scale, Symptom Checklist-90 Revised (SCL-90-R), Zung Self-Rating Anxiety Scale, Beck Depression Inventory, Beck Hopelessness Scale, Millon Clinical Multiaxial Inventory III. Comparison between exposure to the earthquake and COVID pandemic has been made in terms of professional role and psychological burden. Results: Comparison between 2009 earthquake catastrophe and COVID pandemic conditions evidenced relevant changes in professional role, team, environment, shifts, and work organization. Conclusion: The doctors, who already experienced the 2009 earthquake reported a feeling of greater insecurity facing this latter catastrophe, the COVID pandemic, as well as perception of greater concern for their family and the global situation. However, having participated in the medical management of another emergency (the 2009 earthquake) appears to have contributed to limiting demoralization and psychological distress. The feeling of having greater decision-making possibilities and participation in the organization of work, strengthen coping skills in the face of the emergency.

Do changes in SSEP amplitude over time predict the outcome of comatose survivors of cardiac arrest?

AIM: To assess if the amplitude of the N20 wave (N20Amp) of somatosensory evoked potentials (SSEPs) changes between 12-24 h and 72 h from the return of spontaneous circulation (ROSC) after cardiac arrest and if an N20Amp decrease predicts poor neurological outcome (CPC 3-5) at six months. SETTING: Retrospective analysis of the ProNeCA multicentre prognostication study dataset. (NCT03849911). METHODS: In adult comatose cardiac arrest survivors whose SSEPs were recorded at both 12-24 h and 72 h after ROSC, we measured the median N20Amp at each timepoint and the individual change in N20Amp across the two timepoints. We identified their cutoffs for predicting poor outcome with 0% false positive rate (FPR) and compared their sensitivities. RESULTS: We included 236 patients. The median [IQR] N20Amp increased from 1.90 [0.78-4.22] µV to 2.86 [1.52-5.10] µV between 12-24 h and 72 h (p = 0.0019). The N20Amp cutoff for 0% FPR increased from 0.6 µV at 12-24 h to 1.23 µV at 72 h, and its sensitivity increased from 56[48-64]% to 71[63-77]%. Between 12-24 h and 72 h, an N20Amp decrease > 53% predicted poor outcome with 0[0-5]% FPR and 26[19-35]% sensitivity. Its combination with an N20Amp < 1.23 µV at 72 h increased sensitivity by 1% to 72[64-79]%. CONCLUSION: In comatose cardiac arrest survivors, the median N20Amp and its cutoff for predicting poor neurological outcome increase between 12-24 and 72 h after ROSC. An N20Amp decrease greater than 53% between these two timepoints predicts poor outcome with 0% FPR, confirming the unfavourable prognostic signal of a low N20Amp at 72 h.

Effectiveness of Perampanel as the Only Add-on: Retrospective, Multicenter, Observational Real Life Study on epilepsy patients.

OBJECTIVE: Perampanel (PER) is indicated as adjunctive antiseizure medication (ASM) in adolescents and adults with epilepsy. Data from clinical trials show good efficacy and tolerability, while limited information is available on the routine clinical use of PER, especially when used as only add-on treatment. METHODS: we performed an observational, retrospective, multicenter study on people with focal or generalized epilepsy aged >12 years, consecutively recruited from 52 Italian epilepsy centers. All patients received PER as the only add-on treatment to a background ASM according to standard clinical practice. Retention rate, seizure frequency and adverse events were recorded at 3, 6 and 12 months after PER introduction. Sub-analyses by early or late use of PER and by concomitant ASM were also conducted. RESULTS: 503 patients were included (age 36.5±19.9 years). Eighty-one per cent had focal epilepsy. Overall, the retention rate was very high in the whole group (89% at 12 months) according with efficacy measures. No major differences were observed in the sub-analyses, although patients who used PER as early add-on, as compared with late add-on, more often reached early seizure freedom at 3 months follow-up (66% vs. 53%, p=0.05). Treatment-emergent adverse events occurred in 25%, far less commonly than in PER randomized trials. SIGNIFICANCE: this study confirms the good efficacy and safety of PER for focal or generalized epilepsy in real-life conditions. We provide robust data about its effectiveness as only add-on treatment even in patients with a long-standing history of epilepsy and previously treated with many ASMs.

Advanced MRI imaging of nerve roots in lumbar radiculopathy due to discoradicular conflict: DWI, DTI, and T2 mapping with clinical and neurophysiological correlations.

PURPOSE: To evaluate the lumbar nerve root alterations in patients with lumbar disc herniation sciatica using advanced multimodality MRI sequences and the correlations with clinical and neurophysiological findings. MATERIAL AND METHODS: We prospectively evaluated 45 patients suffering from unilateral lumbar radiculopathy due to disco radicular conflict. All patients underwent MRI examinations using a standard MRI protocol and additional advanced MRI sequences (DWI, DTI, and T2 mapping sequences). Relative metrics of ADC, FA, and T2 relaxation times were recorded by placing ROIs at the pre-, foraminal, and post-foraminal level, either at the affected side or the contralateral side, used as control. All patients were also submitted to electromyography testing, recording the spontaneous activity, voluntary activity, F wave amplitude, latency, and motor evoked potentials (MEP) amplitude and latency, both at the level of the tibialis anterior and the gastrocnemius. Clinical features (diseases duration, pain, sensitivity, strength, osteotendinous reflexes) were also recorded. RESULTS: Among clinical features, we found a positive correlation of pain intensity with ADC values of the lumbar nerve roots. The presence of spontaneous activity was correlated with lower ADC values of the affected lumbar nerve root. F wave and MEP latency were correlated with decreased FA values at the foraminal level and increased values at the post-foraminal level. The same neurophysiological measures correlated positively with pre-foraminal T2 mapping values and negatively with post-foraminal T2 mapping values. Increased T2 mapping values at the foraminal level were correlated with disease duration. CONCLUSIONS: Evaluation of lumbar nerve roots using advanced MRI sequences may provide useful clinical information in patients with lumbar radiculopathy, potentially indicating active inflammation/myelinic damage (DTI, T2 mapping) and axonal damage/chronicity (DWI).

Adjunctive Perampanel in Older Patients With Epilepsy: A Multicenter Study of Clinical Practice.

BACKGROUND: Clinical data regarding use of newer antiseizure medications (ASMs) in an older population are limited. In randomized-controlled, placebo-controlled trials, older patients are under-represented, and protocols deviate markedly from routine clinical practice, limiting the external validity of results. Studies performed in a naturalistic setting are a useful complement to characterize the drug profile. Perampanel is a third-generation ASM and the first and only non-competitive alfa-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate receptor antagonist. OBJECTIVE: The aim of this study was to assess the effectiveness and tolerability of adjunctive perampanel over a 1-year period in a population of older patients with epilepsy treated in a real-world setting. METHODS: Older (≥ 65 years of age) patients prescribed add-on perampanel at 12 Italian epilepsy centers were retrospectively identified. Seizure occurrence, adverse events (AEs), and drug withdrawal were analyzed. Effectiveness outcomes included the rates of seizure response (≥ 50% reduction in baseline monthly seizure frequency), seizure freedom, and treatment discontinuation. Safety and tolerability outcomes were the rate of treatment discontinuation due to AEs and the incidence of AEs. RESULTS: A total of 92 patients with a median age of 69 (range 65-88) years were included. The median daily dose of perampanel at 12 months was 6 mg (interquartile range 4-6 mg). At 12 months, 53 (57.6%) patients were seizure responders, and 22 (23.9%) patients were seizure free. Twenty (21.7%) patients discontinued perampanel; the reasons for treatment withdrawal were insufficient efficacy (n = 6/20; 30.0%), AEs (n = 12/20; 60.0%), and a combination of both (n = 2/20; 10%). The most common AEs included irritability (8.7%), somnolence (4.3%), and dizziness/vertigo (4.3%). The rate of behavioral and psychiatric AEs was higher in patients with history of psychiatric comorbidities (p = 0.044). There were no differences in the occurrence of behavioral and psychiatric AEs according to the concomitant use of levetiracetam (p = 0.776) and history of cognitive decline (p = 0.332). CONCLUSIONS: Adjunctive perampanel was associated with improvement in seizure control and good tolerability in a real-life setting and can represent a viable therapeutic option in older patients with epilepsy.

SSEP amplitude accurately predicts both good and poor neurological outcome early after cardiac arrest; a post-hoc analysis of the ProNeCA multicentre study.

AIM: To assess if, in comatose resuscitated patients, the amplitude of the N20 wave (N20amp) of somatosensory evoked potentials (SSEP) can predict 6-months neurological outcome. SETTING: Multicentre study in 13 Italian intensive care units. METHODS: The N20amp in microvolts (µV) was measured at 12 h, 24 h, and 72 h from cardiac arrest, along with pupillary reflex (PLR) and a 30-min EEG classified according to the ACNS terminology. Sensitivity and false positive rate (FPR) of N20amp alone or in combination were calculated. RESULTS: 403 patients (age 69[58-68] years) were included. At 12 h, an N20amp >3 µV predicted good neurological outcome (Cerebral Performance Categories [CPC] 1-2) with 61[50-72]% sensitivity and 11[6-18]% FPR. Combining it with a benign (continuous or nearly continuous) EEG increased sensitivity to 91[82-96]%. For poor outcome (CPC 3-5), an N20Amp ≤0.38 µV, ≤0.73 µV and ≤1.01 µV at 12 h, 24 h, and 72 h, respectively, had 0% FPR with sensitivity ranging from 61[51-69]% and 82[76-88]%. Sensitivity was higher than that of a bilaterally absent N20 at all time points. At 12 h and 24 h, a highly malignant (suppression or burst-suppression) EEG and bilaterally absent PLR achieved 0% FPR only when combined with SSEP. A combination of all three predictors yielded a 0[0-4]% FPR, with maximum sensitivity of 44[36-53]%. CONCLUSION: At 12 h from arrest, a high N20Amp predicts good outcome with high sensitivity, especially when combined with benign EEG. At 12 h and 24 h from arrest a low-voltage N20amp has a high sensitivity and is more specific than EEG or PLR for predicting poor outcome.

Perampanel Improves Cortical Myoclonus and Disability in Progressive Myoclonic Epilepsies: A Case Series and a Systematic Review of the Literature.

Introduction: Progressive myoclonic epilepsies (PMEs) are a heterogenous group of genetic diseases presenting with epilepsy, cognitive impairment, and severe action myoclonus, which can severely affect daily life activities and independent walking ability. Perampanel is a recent commercially available antiseizure medication with high efficacy against generalized seizures. Some reports supported the role of perampanel in ameliorating action myoclonus in PMEs. Here, we aimed to describe a case series and provide a systematic literature review on perampanel effects on PMEs. Methods: We report the perampanel effectiveness on myoclonus, daily life activities, and seizures on an original Italian multicenter case series of 11 individuals with PMEs. Then, using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we performed a systematic review on perampanel effect on myoclonus and disability in PMEs. We searched PubMed, Scopus, and Google Scholar articles on perampanel and PMEs up to June 2020. No prospective trials were found. We reviewed 11 case series manuscripts reporting 104 cases of different PMEs. Results: Here, we are reporting the effectiveness of perampanel in five individuals affected by Unverricht-Lundborg disease, three by Lafora disease, two by sialidosis, and one by an undetermined PME. Nine out of 11 individuals improved their disability related to the action myoclonus (two with Lafora disease did not). Among the 104 persons with PMEs collected by the systematic review, we found that more than half of the patients receiving perampanel exhibited an amelioration of action myoclonus and, consequently, of their independence in daily life activities. The Unverricht-Lundborg disease seemed to show the best clinical response to perampanel, in comparison with the other more severe PMEs. A significant seizure reduction was achieved by almost all persons with active epilepsy. Only 11% of PME patients dropped out due to inefficacy. Conclusions: Perampanel demonstrated a beneficial effect with regard to action myoclonus, disability, and seizures and was well-tolerated in people with PMEs, independently from their genetic diagnosis. Given the limited scientific evidence, broader prospective trials should be encouraged.

Diversified social cognition in temporal lobe epilepsy.

OBJECTIVES: In an integrated model of social cognition (SC), the theory of mind (ToM), the recognition of behavior in social situations (RBSS), empathy, and sensitivity to moral and conventional rules (SMCR) cooperate in generating mental representations of the interpersonal relationships. The aim of this study was to extend our knowledge of the SC of temporal lobe epilepsy (TLE) patients by characterizing its various aspects and predictors. MATERIALS AND METHODS: Fifty adult patients with TLE and 50 healthy controls were assessed using ToM, RBSS and SMCR neuropsychological tests, the Empathy Questionnaire, and the psychopathology Symptoms Check List 90R (SCL90-R). RESULTS: Patients and controls were similar in terms of occupation, income level, age, sex, marital status and the number of family members. Multivariate analysis of variance with demographic variables as the covariates showed that they were similar in SMCR and empathy. The patients, conversely, had lower ToM and RBSS scores, and higher scores on the SCL90-R psychoticism, depression, paranoid ideation, obsessive-compulsive, somatization and anxiety scales. Impaired RBSS was predicted by psychopathological symptoms, income level, schooling and the duration of epilepsy; ToM related to TLE laterality, seizure frequency and epilepsy duration. CONCLUSIONS: In adult patients with TLE, SC is simultaneously partially impaired and partially preserved, and the fact this is associated with clinical, demographic and psychological variables suggests that SC depends on the integrity of the temporal lobe and the interconnected brain regions, as well as psychosocial stimuli. This approach may contribute to clarify the neurobehavioural phenotype of TLE.

Brivaracetam as add-on treatment in focal epilepsy: A real-world time-based analysis.

The study assessed the clinical response to add-on brivaracetam (BRV) in real-world practice by means of time-to-baseline seizure count methodology. Patients with focal epilepsy who were prescribed add-on BRV were identified. Primary endpoint was the time-to-baseline seizure count defined as the number of days until each patient experienced the number of focal seizures that occurred in the 90 days before BRV initiation. Subgroup analysis was performed according to levetiracetam (LEV) status (naive vs prior use). Three-hundred eighty-seven patients were included. The overall median time-to-baseline seizure count was 150 (95% confidence interval [CI] = 130-175) days. The median time-to-baseline seizure count was 198 (lower limit of 95% CI = 168) days for LEV-naive patients, 126 (95% CI = 105-150) days for patients with prior LEV use and withdrawal due to insufficient efficacy, and 170 (95% CI = 128-291) days for patients who discontinued LEV due to adverse events (P = .002). The number of prior antiseizure medications (adjusted hazard ratio [adj HR] = 1.07, 95% CI = 1.02-1.13, P = .009) and baseline monthly seizure frequency (adj HR = 1.004, 95% CI = 1.001-1.008, P = .028) were independently associated with the primary endpoint. Add-on BRV improved seizure control in LEV-naive and LEV-prior patients. The time-to-baseline seizure count represents an informative endpoint alongside traditional study outcomes and designs.

Does a combination of ≥2 abnormal tests vs. the ERC-ESICM stepwise algorithm improve prediction of poor neurological outcome after cardiac arrest? A post-hoc analysis of the ProNeCA multicentre study.

BACKGROUND: Bilaterally absent pupillary light reflexes (PLR) or N20 waves of short-latency evoked potentials (SSEPs) are recommended by the 2015 ERC-ESICM guidelines as robust, first-line predictors of poor neurological outcome after cardiac arrest. However, recent evidence shows that the false positive rates (FPRs) of these tests may be higher than previously reported. We investigated if testing accuracy is improved when combining PLR/SSEPs with malignant electroencephalogram (EEG), oedema on brain computed tomography (CT), or early status myoclonus (SM). METHODS: Post-hoc analysis of ProNeCA multicentre prognostication study. We compared the prognostic accuracy of the ERC-ESICM prognostication strategy vs. that of a new strategy combining ≥2 abnormal results from any of PLR, SSEPs, EEG, CT and SM. We also investigated if using alternative classifications for abnormal SSEPs (absent-pathological vs. bilaterally-absent N20) or malignant EEG (ACNS-defined suppression or burst-suppression vs. unreactive burst-suppression or status epilepticus) improved test sensitivity. RESULTS: We assessed 210 adult comatose resuscitated patients of whom 164 (78%) had poor neurological outcome (CPC 3-5) at six months. FPRs and sensitivities of the ≥2 abnormal test strategy vs. the ERC-ESICM algorithm were 0[0-8]% vs. 7 [1-18]% and 49[41-57]% vs. 63[56-71]%, respectively (p < .0001). Using alternative SSEP/EEG definitions increased the number of patients with ≥2 concordant test results and the sensitivity of both strategies (67[59-74]% and 54[46-61]% respectively), with no loss of specificity. CONCLUSIONS: In comatose resuscitated patients, a prognostication strategy combining ≥2 among PLR, SSEPs, EEG, CT and SM was more specific than the 2015 ERC-ESICM prognostication algorithm for predicting 6-month poor neurological outcome.

[Mindfulness attitude, emotions and forgiveness in adolescence: a correlational research]. / Attitudine "mindful", emozioni e perdono di sé in adolescenza: una ricerca correlazionale.

INTRODUCTION: Mindfulness indicates a state of mind, connected with attention and awareness that can be developed and cultivated through meditation. PURPOSE: The research hypothesis foresees that the mindfulness attitude significantly correlates with the psychological variables considered: anger, anxiety, depression and feelings towards oneself (self-hatred, inadequacy of the self and self-forgiveness). The aim of this research was to highlight the relationship between mindfulness attitude and previous constructions in a sample of italian teenagers. METHODS: The sample includes 867 subjects, aged between 13 and 20, from the region of Lazio (Rieti and Rome). The participants compiled, under supervision, a battery of tests consisting of self-report questionnaires. To evaluate the psychological dimensions of our interest, we used four measures: CAMS-R, CDI, STAI-Y Trait, STAXI C/A, FSCRS. RESULTS: The study highlighted significantly a positive correlations between high mindfulness disposition and psychological well-being. Specifically, the study showed that adolescents with a high mindfulness disposition are less depressed, less anxious and angry and they have a higher ability to forgive themselves. DISCUSSION: The mindfulness attitude is a tendency that individuals can present to a greater or lesser extent, regardless of the practice of mindfulness. The data obtained from this study support the prospective for further investigations that could lead to improvements in terms of psychological well-being.

Glimpsing the Impact of COVID19 Lock-Down on People With Epilepsy: A Text Mining Approach.

Objectives: To describe how the recent lock-down, related to SARS-COV-II outbreak in Italy, affected People With Epilepsy (PwE), we designed a survey focused on subjective reactions. Using Natural Language Processing (NLP), we analyzed words PwE and People without Epilepsy (PwoE) chose to express their reactions. Methods: As a subset of a larger survey, we collected from both PwE (427) and PwoE (452) single words (one per subject) associated to the period of lock down. The survey was spread thanks to the efforts of Italian league against epilepsy Foundation during the days of maximum raise of the pandemic. Data were analyzed via bag of word and sentiment analysis techniques in R. Results: PwoE and PwE showed significantly different distribution in word choice (X2, p = 4.904e-13). A subset of subject used positive words to describe this period, subjects with positive feelings about the lock down were more represented in the PwE group (X2, p = 0.045). Conclusion: PwoE developed reactive stress response to the restrictions enacted during lock-down. PwE, instead, chose words expressing sadness and concern with their disease. PwE appear to internalize more the trauma of lock down. Interestingly PwE also expressed positive feelings about this period of isolation more frequently than PwoE. Our study gives interesting insights on how People with Epilepsy react to traumatic events, using methods that evidence features that do not emerge with psychometric scales.

Cognitive, adaptive, and behavioral effects of adjunctive rufinamide in Lennox-Gastaut syndrome: A prospective observational clinical study.

INTRODUCTION: Lennox-Gastaut syndrome (LGS) is a severe pediatric epilepsy syndrome characterized by multiple drug-resistant seizure types. Children with LGS usually experience cognitive regression, and LGS is almost always associated with moderate to severe cognitive impairment. Rufinamide (RFM) was approved by the European Medicines Agency in 2007 for the adjunctive treatment of seizures associated with LGS in patients ≥4 years of age. The primary objective of our study was to assess cognitive, adaptive, and behavior functioning of patients with LGS after 12 months of RFM therapy. METHODS: This was an observational, multicenter, prospective study involving 16 patients diagnosed with LGS aged between 7 and 58 years (mean = 22 ±â€¯16.3). Fourteen of 16 patients were already on therapy with 3 antiseizure drugs and 2/16 with 4 antiseizure drugs; RFM has been added with 100 mg/week increments up to a dose of 300-2400 mg/day. The participants and their parents underwent a neuropsychological evaluation for the assessment of intellectual, adaptive, and emotional/behavioral functioning (Leiter International Performance Scale-Revised (LEITER-R), Vineland, and Child Behavior CheckList (CBCL), respectively) before the RFM introduction (baseline) and 12 months after the RFM therapy (T2). Physical and neurological examination, electroencephalography (EEG) recording, seizure type and frequency, and adverse reactions were also considered. RESULTS: After 12 months, the total intelligence quotient (IQ) assessed by LEITER-R did not show statistical significant changes, such as there were no statistically significant changes in adaptive functions, assessed by Vineland. Furthermore, there were no statistically significant changes in internalizing and externalizing problems assessed by CBCL. CONCLUSION: Adjunctive treatment with RFM did not negatively affect cognitive, adaptive function, and emotional profile in patients with LGS after 1 year of follow-up.

Neurophysiology for predicting good and poor neurological outcome at 12 and 72 h after cardiac arrest: The ProNeCA multicentre prospective study.

AIMS: To assess the accuracy of electroencephalogram (EEG) and somatosensory evoked potentials (SEPs) recorded at 12 and 72 h from resuscitation for predicting six-months neurological outcome in patients who are comatose after cardiac arrest. METHODS: Prospective multicentre prognostication study. EEG was classified according to the American Clinical Neurophysiology Society terminology. SEPs were graded according to the presence and amplitude of their cortical responses. Neurological outcome was defined as good (cerebral performance categories [CPC] 1-3) vs. poor (CPC 4-5). None of the patients underwent withdrawal of life-sustaining treatment. RESULTS: A total of 351 patients were included, of whom 134 (38%) had good neurological outcome. At 12 h, a continuous, nearly continuous and low-voltage EEG pattern predicted good neurological outcome with 71[61-80]% sensitivity, while an isoelectric EEG and a bilaterally absent/absent-pathological amplitude (AA/AP) cortical SEP pattern predicted poor neurological outcome with 14[8-21]% and 59[50-68]% sensitivity, respectively. Specificity was 100[97-100]% for all predictors. At 72 h, both an isoelectric, suppression or burst-suppression pattern on EEG and an AA/AP SEP pattern predicted poor outcome with 100[97-100]% specificity. Their sensitivities were 63[55-70]% and 66[58-74]%, respectively. When EEG and SEPs were combined, sensitivity for poor outcome prediction increased to 79%. CONCLUSIONS: In comatose resuscitated patients, EEG and SEPs predicted good and poor neurological outcome respectively, with 100% specificity as early as 12 h after cardiac arrest. At 72 h after arrest, unfavourable EEG and SEP patterns predicted poor neurological outcome with 100% specificity and high sensitivity, which further increased after their combination.

Neurophysiological and neuroradiological test for early poor outcome (Cerebral Performance Categories 3-5) prediction after cardiac arrest: Prospective multicentre prognostication data.

The data presented here are related to our research article entitled "Neurophysiology and neuroimaging accurately predict poor neurological outcome within 24 hours after cardiac arrest: a prospective multicentre prognostication study (ProNeCA)" [1]. We report a secondary analysis on the ability of somatosensory evoked potentials (SEPs), brain computed tomography (CT) and electroencephalography (EEG) to predict poor neurological outcome at 6 months in 346 patients who were comatose after cardiac arrest. Differently from the related research article, here we included cerebral performance category (CPC) 3 among poor outcomes, so that the outcomes are dichotomised as CPC 1-2 (absent to mild neurological disability: good outcome) vs. CPC 3-5 (severe neurological disability, persistent vegetative state, or death: poor outcome). The accuracy of the index tests was recalculated accordingly. A bilaterally absent/absent-pathological amplitude (AA/AP) N20 SEPs wave, a Grey Matter/White Matter (GM/WM) ratio <1.21 on brain CT and an isoelectric or burst suppression EEG predicted poor outcome with 49.6%, 42.2% and 29.8% sensitivity, respectively, and 100% specificity. The distribution of positive results of the three predictors did not overlap completely in the population of patients with poor outcome, so that when combining them the overall sensitivity raised to 61.2%.

Hopelessness in persons with epilepsy: Relationship with demographic, clinical, and social variables.

Persons with epilepsy show a higher risk of suicidal ideation and behavior than the general population. Hopelessness, as a feature of demoralization, is considered an emerging risk factor for suicidal ideation. Psychopathological comorbidity, mainly depression, has to be taken into account to predict suicidal attempts but the relationship between suicidality and epilepsy has been also reported independently from depressive disorders. The aim of the study was to investigate hopelessness in a sample of persons suffering from epilepsy without comorbidity with psychiatric disorders and its association with demographic, social, and clinical variables, putatively predictive of suicidal behaviors. Beck Hopelessness Scale (BHS) has been used as measure of suicidal ideation in 72 consecutive outpatients afferent to a third level epilepsy center. Exclusion criterion was psychiatric comorbidity evaluated by clinical approach and quantified by Clinical Global Impression (CGI) Scale. Clinical (focus localization, age at onset, number of drugs), demographic, social variables, and intellectual level were considered. Age, age at onset, gender, intellectual level, socioeconomic status, duration of illness and therapy, number of drugs, seizure frequency, and localization of the epileptic focus and side involved were found associated with BHS score increase. In a sample of persons with epilepsy, without psychiatric comorbidity, our data show an association between factors related to the biological pathophysiology and the clinical course of the disease with the sociodemographic status, as a risk factor for suicidal ideation.

Neurophysiology and neuroimaging accurately predict poor neurological outcome within 24 hours after cardiac arrest: The ProNeCA prospective multicentre prognostication study.

AIMS: To investigate the ability of 30-min electroencephalogram (EEG), short-latency somatosensory evoked potentials (SEPs) and brain computed tomography (CT) to predict poor neurological outcome (persistent vegetative state or death) at 6 months in comatose survivors of cardiac arrest within 24 h from the event. METHODS: Prospective multicentre prognostication study in seven hospitals. SEPs were graded according to the presence and amplitude of their cortical responses, EEG patterns were classified according to the American Clinical Neurophysiology Society terminology and brain oedema on brain CT was measured as grey/white matter (GM/WM) density ratio. Sensitivity for poor outcome prediction at 100% specificity was calculated for the three tests individually and in combination. None of the patients underwent withdrawal of life-sustaining treatments before the index event occurred. RESULTS: A total of 346/396 patients were included in the analysis. At 6 months, 223(64%) had poor neurological outcome; of these, 68 were alive in PVS. Bilaterally absent/absent-pathological amplitude cortical SEP patterns, a GM/WM ratio<1.21 on brain CT and isoelectric/burst-suppression EEG patterns predicted poor outcome with 100% specificity and sensitivities of 57.4%, 48.8% and 34.5%, respectively. At least one of these unfavourable patterns was present in 166/223 patients (74.4% sensitivity). Two unfavourable patterns were simultaneously present in 111/223 patients (49.7% sensitivity), and three patterns in 38/223 patients (17% sensitivity). CONCLUSIONS: In comatose resuscitated patients, a multimodal approach based on results of SEPs, EEG and brain CT accurately predicts poor neurological outcome at 6 months within the first 24 h after cardiac arrest.

Multimodal Neurophysiological Monitoring Reduces Shunt Incidence during Carotid Endarterectomy.

BACKGROUND: The use of shunt during carotid surgery is controversial. Different experiences are found in literature with transcranial Doppler (TCD), electroencephalogram (EEG), stump pressure (SP), and somatosensorial evoked potentials (SSEP). METHODS: We realized a retrospective analysis of patients treated with carotid endarterectomy in our unit in the last 2 years. We use several cerebral monitoring: until 2017 we preferred SP + TCD, and, if not available, EEG. Since 2017 we introduced EEG with SSEP, always in association with SP. We analyzed those 2 groups of patients: before and after introduction of EEG with SSEP. RESULTS: From January 2016 to December 2018 we performed 156 carotid revascularizations. In the first group of 93 patients treated under combined SP + TCD (or EEG), we observed 1 stroke (1.1%) and 2 transient ischemic attacks (TIAs) (2.1%); we selectively used a shunt in 21 cases (22.5%). In the second group, 63 patients had an SP + EEG with SSEP monitoring; we observed 1 stroke (1.5%) and 2 TIAs (3.1%), a shunt was necessary in 12 cases (12.9%). CONCLUSIONS: In our experience, EEG with SSEP represents an effective parameter to indicate shunt positioning, as we were able to reduce its use, with the same incidence of stroke and TIA.