Psychiatric manifestations of nonconvulsive status epilepticus
Nonconvulsive status epilepticus (NCSE) is clinically characterized by altered mental status and the diagnosis is confirmed by electroencephalography. Absence status (AS) and complex partial status (CPS) are the two primary types of NCSE. Patients in NCSE may exhibit a wide range of clinical presentations including subtle memory deficits, bizarre behavior, psychosis, or coma. While prognosis is dependent on the underlying etiology and possibly related to duration of the event, there is limited research in this area. Treatment focuses on correcting underlying pathologic abnormalities such as hyponatremia or drug toxicity, and initiating pharmacologic therapy. The benzodiazepines are considered the first line treatment for both AS and CPS.
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- "Approximately two to ten percent of all patients presenting to US emergency departments (EDs) present with altered mental status (AMS), with the most frequent underlying cause being neurological disease . Studies show that ED patients with AMS whose initial evaluation includes EEG are diagnosed more accurately and sooner than those without an EEG [2-9]. Despite its utility, routine use of EEG in the ED faces numerous obstacles. "
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We describe and characterize the performance of microEEG compared to that of a commercially available and widely used clinical EEG machine. microEEG is a portable, battery-operated, wireless EEG device, developed by Bio-Signal Group to overcome the obstacles to routine use of EEG in emergency departments (EDs).
The microEEG was used to obtain EEGs from healthy volunteers in the EEG laboratory and ED. The standard system was used to obtain EEGs from healthy volunteers in the EEG laboratory, and studies recorded from patients in the ED or ICU were also used for comparison. In one experiment, a signal splitter was used to record simultaneous microEEG and standard EEG from the same electrodes.
EEG signal analysis techniques indicated good agreement between microEEG and the standard system in 66 EEGs recorded in the EEG laboratory and the ED. In the simultaneous recording the microEEG and standard system signals differed only in a smaller amount of 60 Hz noise in the microEEG signal. In a blinded review by a board-certified clinical neurophysiologist, differences in technical quality or interpretability were insignificant between standard recordings in the EEG laboratory and microEEG recordings from standard or electrode cap electrodes in the ED or EEG laboratory. The microEEG data recording characteristics such as analog-to-digital conversion resolution (16 bits), input impedance (>100MΩ), and common-mode rejection ratio (85 dB) are similar to those of commercially available systems, although the microEEG is many times smaller (88 g and 9.4 × 4.4 × 3.8 cm).
Our results suggest that the technical qualities of microEEG are non-inferior to a standard commercially available EEG recording device. EEG in the ED is an unmet medical need due to space and time constraints, high levels of ambient electrical noise, and the cost of 24/7 EEG technologist availability. This study suggests that using microEEG with an electrode cap that can be applied easily and quickly can surmount these obstacles without compromising technical quality.
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ABSTRACT: The diagnosis of nonconvulsive status epilepticus (NCSE) is particularly challenging in elderly patients. Confusion, personality change, dysphasia, subtle motor activity and nystagmus may be the only presenting signs.
To review current knowledge about NCSE with special focus on older people.
Systematic review of the current literature via Medline search.
Although prospective studies are still lacking, NCSE may be one of the most frequently missed diagnoses in patients presenting with altered mental status. Elderly patients are at particular risk of diagnostic errors because of the broad range of presentations of NCSE, significant comorbidities (especially cerebrovascular disease), limited awareness of this particular seizure emergency or difficulties with access to electroencephalography. Although diagnostic criteria and treatment remain controversial, the diagnosis of NCSE is important because it is potentially reversible.
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ABSTRACT: Syncope combines loss of consciousness and inability to maintain postural tone. Prevalence in the subjects aged of 70 years and older is near 30%. In most cases, several causes lead to syncope. The main mechanisms are heart disease, dysautonomy and miscellaneous conditions like anemia varicosis, or drugs with anticholinergic effects. Anamnesis and physical examination lead to the diagnosis in up to 50%. The decision for further diagnostic tests often depends on the evidence of an underlying heart disease. Blood tests, ECG and search of arterial hypotension must be systematically performed. In absence of diagnosis, prolonged ECG monitoring and echocardiography, are the second step exploration. Then tilt test, cardiac electrophysiological study, electroencephalogram may be discussed according to the efficient strategy for the patient. The most important step is to diagnose heart disease because the mortality is doubled in these cases. About 10% of syncopes remained unexplained in the elderly. But their prognosis is not significantly different from that of syncopes of non cardiac origin. So there is no reason to perform invasive explorations to discover etiology in this context. For elderly patients admitted in an emergency ward, the San Francisco Rule aids physician's decision making and performs better than current physician performance to predict prognosis in the first week after syncope. Protocol care must to be developed in geriatric institutions to increase the quality of diagnosis and treatment of elderly subjects after loss of consciousness.
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