Comparative Study of the Effect of Midazolam Administration Before and after Seizures on the Prevention of Complications in Children Undergoing Electroconvulsive Therapy Compared with a Control Group

Background: One of the complications of ECT treatment is headache. There is a need to use sedation during ECT. As a result, midazolam has been used to address a safe and effective strategy in this regard. Methods: This study is a double-blind clinical trial that has been performed in three groups: group A, which receives midazolam based on the usual regimen, group B, which receives midazolam after shock, and group C, which is the control group. Patients were asked about headache, nausea, and muscle aches during the recovery time, seizure duration and after becoming fully conscious. Data were analyzed in the PASW version18 software using analysis of variance and repeated measurement tests, ANOVA, independed t and χ2 tests. Results: Analysis showed that the frequency of muscle pain after full consciousness in group C was significantly higher than group B, with group B being higher than group A. χ2 test showed that the frequency of headache, cough and nausea in group C was significantly higher than the two groups A and B. Conclusion: The result of this research showed that midazolam prodrug plays an effective role in preventing post-ECT complications in children. The effect of midazolam before and after ECT on headache, muscle pain and nausea was investigated and compared with the control group. Also, due to its anterograde amnesia, midazolam can reduce the patient's stress in the next visits, and this issue is even more important when the patient is a child.

The Influence of Anaesthetic Choice on Electroconvulsive Therapy Parameters; Etomidate Versus Methohexital

Background Many of the anaesthetic drugs used for electroconvulsive therapy have anticonvulsant properties and may influence efficacy of electroconvulsive therapy. With this study we aim to provide more information on the effect of etomidate and methohexital on seizure duration. We explore the relationship between induction drug, motor and electroencephalography seizure duration. Moreover, we study the relationship of seizure duration and number of therapies. Methods In this retrospective study we collected data from patient records from 2005 until 2016. Inclusion criteria were the use of etomidate and/or methohexital and documentation of dosage, electroconvulsive therapy dosage and seizure duration. Exclusion criteria were missing data on either induction drug, dosage or seizure duration. Results Thirty seven patients were analysed. The mean age was 52 years and seventy six percent were female. Most patients were suffering from affective disorders (81%). Motor and electroencephalography seizure duration were analysed in 679 and 551 electroconvulsive therapies, respectively. Compared to methohexital, motor and electroencephalography seizures under etomidate were 7 and 13 seconds longer, respectively. Furthermore, there was a negative association between seizure duration and number of treatment and a negative association between seizure duration and electroconvulsive therapy dosage. Conclusions This study demonstrates significant longer motor and electroencephalography seizure duration using etomidate compared to methohexital. Etomidate might therefore increase the effectiveness of electroconvulsive therapy. Moreover, we observed a negative association between seizure duration, number of treatment and electroconvulsive therapy dosage. With this study we contribute to the available literature comparing methohexital and etomidate as induction agents for electroconvulsive therapy.

Characteristics of Patient with Status Epilepticus at the Emergency Department of Sanglah General Hospital

Introduction: Status epilepticus is a neurological condition caused by a failure of body mechanism to terminate the seizures or the onset of abnormal seizure activity resulting in prolonged seizure’s duration for more than five minutes. The available research data on status epilepticus in Indonesia is still limited. The purpose of this study was to determine the profile of patients with status epilepticus at Sanglah General Hospital from 2020 to 2021. Methods: This was a descriptive study with a retrospective approach. The study populations were patients with status epilepticus who were treated at Sanglah General Hospital in 2019-2020 who had no missing data in the medical records. Results: There were 117 patients with status epilepticus, 63 males (53.8%) and 54 females (46.2%). There are 41 patients>60 years (35%), general onset in 63 patients (53.8%), and focal onset in 54 patients (46.2%). Etiology from cerebral was 68 patients (58.1%), followed by metabolic in 28 patients (23.9%). The most common OAE therapy was phenytoin (86.3%) and the longest length of stay status epilepticus patients was 8 days (55.6%). Patients with status epilepticus had leukocytosis (73.5%), increased NLR (66.7%), and decreased mean platelet volume (53.8%). Conclusion: The highest incidence of status epilepticus is in women, above 60 years, general onset type of seizure, and etiology from cerebral. Initial therapy in 117 patients was intravenous diazepam followed by phenytoin for maintenance. NLR increased in most of the patients showing signs of inflammation which further worsened the patient's outcome with a mortality rate of 47%. Keywords: Status epilepticus, seizure duration, anticonvulsant, neutrophil-lymphocyte ratio.

Predicting the Onset of Acute Encephalopathy With Biphasic Seizures and Late Reduced Diffusion by Using Early Laboratory Data

Background: Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) often causes various neurological sequelae, necessitating early and objective differentiation of AESD from a febrile seizure (FS). Therefore, we developed a scoring system that predicts AESD onset using only early laboratory data.Methods: We selected patients with AESD or FS admitted to the Tottori University Hospital between November 2005 and September 2020 and collected laboratory data from onset to discharge in patients with FS and from onset to the second neurological events in patients with AESD.Results: We identified 18 patients with AESD and 181 patients with FS. In comparison with patients with FS, patients with AESD showed statistically significant increases in ammonia (NH3), blood sugar (BS), and serum creatinine (Cr) levels, and the white blood cell (WBC) count, and a significant decrease in pH at <3 h from onset. We set the cut-off values and adjusted the weight of each of these parameters based on data obtained <3 h from onset and proposed a scoring system for predicting AESD. This system showed 91% sensitivity and 94% specificity for distinguishing AESD from FS. These accuracies were only slightly improved by the addition of information related to consciousness and seizure duration (sensitivity, 91%; specificity, 96%).Conclusion: NH3, BS, and Cr levels, WBC count, and pH were significantly different between patients with AESD and patients with FS at <3 h from seizure onset. This scoring system using these data may enable the prediction of AESD onset for patients under sedation or without precise clinical information.

Fruit flies subjected to TBI exhibit genotype-dependent changes in seizure incidence and duration

Traumatic brain injury (TBI) is common and often debilitating. One complication following TBI is post-traumatic seizures (PTS). However, there is a poor understanding of PTS, in part, because it is challenging to model. We sought to develop a fly model of PTS. We used a high-impact trauma (HIT) device to inflict TBI and followed this with behavioral, bang-testing methods to assess seizure behavior. Our results showed PTS incidence was sensitive to genetic background. We also found seizure duration was most pronounced at 30 minutes after injury. Our findings support the efficacy of our fly model for coarse screening of seizure behavior. We expect this model will be useful in first-pass screens intended to identify modifiers of seizure risk following TBI.

Adding a Low Dose of Fentanyl to Propofol in Patients Receiving Electroconvulsive Therapy: A Randomized Controlled Trial

Objective: To evaluate the effects of low-dose fentanyl combined with a reduced dose of propofol on seizure duration and hemodynamic response during electroconvulsive therapy (ECT). Materials and Methods: Twenty-two patients with the American Society of Anesthesiologist Physical Status II to III undergoing ECT were enrolled in the present study. One hundred and five bilateral ECT sessions randomized to receive thiopental 2 mg/kg, propofol 1 mg/kg, and fentanyl 0.3 mcg/kg, followed by propofol 0.5 mg/kg. Succinylcholine 0.5 mg/kg was used for muscle paralysis. Seizure duration, awakening time and hemodynamic changes were compared between groups. Results: One hundred and five bilateral ECT treatments were randomized into thiopental group (n=35), propofol group (n=35), and fentanyl plus propofol group (n=35). The thiopental and fentanyl plus propofol groups had longer EEG and motor seizure durations than the propofol group, but the differences were not statistically significant. There was no difference in stimulus intensity across groups. However, fentanyl plus propofol group had statistically significant prolonged awakening time compare with thiopental group [mean difference 2.71, (95% CI 0.37 to 5.06, p=0.019)] and propofol group (mean difference 2.77, 95% CI 0.42 to 5.12, p=0.016). Only systolic blood pressure in propofol group was significantly lower than thiopental group [mean difference –10.4, (95% CI –19.4 to –1.38, p=0.018)]. There were no significant differences in diastolic blood pressure (df=2, F=2.546, p=0.083), heart rate (df=2, F=0.596, p=0.553), or oxygen saturation across group (df=2, F=2.914, p=0.059). Conclusion: Using a combination of low-dose fentanyl and low-dose propofol during ECT could be beneficial. Further investigation is needed to establish the optimal dose of propofol and fentanyl. Keywords: Electroconvulsive therapy; Fentanyl, Hemodynamic response; Propofol; Thiopental; Seizure duration

The Role of the Temporal Pole in Temporal Lobe Epilepsy: A Diffusion Kurtosis Imaging Study

Objective: This study aims to evaluate the use of diffusion kurtosis imaging (DKI) to detect microstructural abnormalities within the temporal pole (TP) in temporal lobe epilepsy (TLE) patients. Methods: DKI quantitative maps were obtained from fourteen lesional (MRI+) and ten non-lesional (MRI-) TLE patients, along with twenty-one healthy controls. This included mean (MK); radial (RK) and axial kurtosis (AK); mean diffusivity (MD) and axonal water fraction (AWF). Automated fiber quantification (AFQ) was used to quantify DKI measurements along the inferior longitudinal (ILF) and uncinate fasciculus (Unc). ILF and Unc tract profiles were compared between groups and tested for correlation with seizure duration. To characterize temporopolar cortex (TC) microstructure, DKI maps were sampled at varying depths from superficial white matter (WM) towards the pial surface. Each patient group was separated according to side ipsilateral to the epileptogenic temporal lobe and their AFQ results were used as input for statistical analyses. Results: Significant differences were observed between MRI+ and controls (p < 0.005), towards the most anterior of ILF and Unc proximal to the TP of the left (not right) ipsilateral temporal lobe for MK, RK, AWK and MD. Noticeable differences were also observed mostly towards the TP for MK, RK and AWK in the MRI- group. DKI measurements correlated with seizure duration, mostly towards the anterior segments of the WM bundles. Stronger differences in MK, RK and AWF within the TC were observed in the MRI+ and noticeable differences (except for MD) in MRI- groups compared to controls. Significance: The study demonstrates that DKI has potential to detect subtle microstructural alterations within the anterior segments of the ILF and Unc and the connected TC in TLE patients including MRI- subjects. This could aid our understanding of the extrahippocampal areas involved in seizure generation in TLE and might inform surgical planning, leading to better seizure outcomes.

Evaluating Factors Affecting the Time Interval Between Propofol Injection and Induction of Electro-convulsion and Relationship Between These Factors and Duration of Convulsion

Background: Current evidence on the effect of anesthetic-ECT time interval (AETI) is controversial. This study aimed to investigate the factors affecting the time interval between propofol injection and electro-convulsion induction and the relationship between these factors and the duration of convulsion. Methods: In this study, 102 patients (616 sessions of ECT) were studied. Demographic and clinical data (age, gender, receiving or not receiving medications that affected the seizure threshold, the total number of ECT sessions, clinical severity of admission scores, clinical diagnosis, propofol dose, seizure duration, and AETI) were collected in special forms and analyzed by appropriate statistical methods. Results: Sessions with long-term AETI had longer seizure time than sessions with short-term AETI (33.47 ± 8.46 vs. 28.68 ± 9.74, P value < 0.05). The duration of seizures was significantly longer in the group with long AETI in sessions 1, 2, and 4 than in the other group (P value < 0.05). There was a significant relationship between the duration of seizures and propofol dose, AETI, and receiving drugs effective in the seizure threshold (P value < 0.05). Conclusions: The results showed that increasing AETI and injecting a lower dose of propofol to induce anesthesia would increase the duration of seizures. Also, taking medications that would affect the seizure threshold reduces the duration of seizures.

A Narrative Overview of Current Anesthetic Drugs in Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a definitive treatment for patients with psychiatric disorders that are severe, acute, or refractory to pharmacologic therapy. Providing anesthesia for ECT is challenging, as the effect of drugs on hemodynamics, seizure duration, comfort, and recovery must be considered. We highlight and aim to review the common anesthetics used in ECT and related evidence. While drugs such as methohexital, succinylcholine, and etomidate have been used in the past, other drugs such as dexmedetomidine, ketamine, and remifentanil may provide a more balanced anesthetic with a greater safety profile in select populations. Overall, it is essential to consider the patient’s co-morbidities and associated risks when deciding on an anesthetic drug.