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By: H. Owen, M.B. B.CH. B.A.O., Ph.D.

Clinical Director, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo

Inability to precisely locate a cortical generator may be the result of spatial undersampling ("aliasing") medicine and science in sports and exercise discount dilantin 100 mg mastercard. The assumption that a potential will decrease monotonically as distance increases from the involved electrode is based not only on an uncomplicated electrical field, that is, a monopole, but also on an electrode placement sufficiently dense to accurately represent the spatial contours of the field. Because most epileptogenic potentials seen on the scalp are visible at multiple electrodes, a considerably larger cortical area must be synchronously discharging to produce these potentials. Especially controversial is the detectability of spikes generated in the mesial temporal lobe. Sphenoidal electrodes provide a significantly better view of the mesial area, as shown in Figure 7. When more precise localization is indicated to avoid spatial aliasing, scalp electrodes should be placed at least once every 2. The maximum spacing can be determined theoretically (65) as well as experimentally, and as many as 128 electrodes (spaced approximately 2 cm apart) may sometimes be necessary (66). Top: Surface electrode B sees a large electrical potential because of the orientation and proximity of the dipole layer, as borne out by the solid angle B. Bottom: In this case, the potential seen by electrode A is actually lower than that measured by the more distant electrode B because of the arrangement of the dipoles in the discharging region. Chapter 7: Localization and Field Determination in Electroencephalography 77 output. These devices, called differential amplifiers, eliminate unwanted signals that are identical at both inputs, called common-mode signals. The two terminals at the input to a differential amplifier are sometimes labeled G1 and G2, recalling when a screened "grid" within the vacuum tube amplifier controlled the flow of electrons from cathode to plate. Modern opamp-based differential amplifiers employ complex integrated circuits, and the terms "input 1" and "input 2" are used throughout this chapter. Note that in the conventional double-banana longitudinal montage without the sphenoidals, this discharge is almost invisible. Boundary Problems Regardless of the fineness of the scalp electrode grid, boundary effects will occur at the edges of the array. The maximum potential must be well within the scope of the recording electrodes to ascertain that a physiologic gradient exists away from the electrode. It is impossible to determine the complete extent of the maximum fields unless the area is surrounded by regions of lesser activity. Recordings in which the activity is large all the way to the boundary of the region defined by the montage must be "remontaged" to include, if possible, all the relevant electrodes, or further recording must be carried out with additional electrodes. This may be especially complicated when it is difficult to position electrodes inferior to the customary borders of scalp coverage. A significant portion of the head cannot be practically surveyed and important brain areas such as the basomesial temporal cortex and other deep sources are only indirectly accessible with standard scalp electrodes. Inexperienced electroencephalographers often mistakenly ascribe a polarity at the input to a specific pen deviation at the output (12). It should be remembered that there are no positive deflections and no negative deflections. Because a differential amplifier responds only to the difference between the two inputs (input 1 input 2), the spikes illustrated will yield identical output voltages; (80) (0) is the same as (120) (40). The background electroencephalogram activity, because it is more widespread than the spikes and therefore almost the same at both inputs, is largely canceled out. In C and D, the spike is surface positive, that is, input 2 is more positive than input 1. All four circumstances yield identical outputs despite the differing amplitudes and polarities.

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It is intended for internal use only and should be disseminated only to authorized recipients treatment diarrhea cheap 100 mg dilantin amex. The contents of the therapeutic class overviews on this website ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Patients should always seek the advice of a physician or other qualified health provider with any questions regarding a medical condition. Clinicians should refer to the full prescribing information and published resources when making medical decisions. Dalfampridine is contraindicated in patients with a history of seizure, moderate or severe renal impairment (CrCl 50 mL/min), and a history of hypersensitivity to dalfampridine or 4-aminopyridine. Dalfampridine can cause anaphylaxis; signs and symptoms of anaphylaxis have included respiratory compromise, urticaria, and angioedema of the throat and or tongue. Dosing and Administration* Available Usual Recommended Drug Route Formulations Frequency Ampyra (dalfampridine) Tablets Oral Twice daily Comments May be taken with or without food. In patients with mild renal impairment (CrCl 51 to 80 mL/min), dalfampridine may reach plasma levels associated with a greater risk of seizures, and the potential benefits of Ampyra should be carefully considered against the risk of seizures in these patients. Dalfampridine is contraindicated in patients with moderate or severe renal impairment (CrCl 50 mL/min). No dosage adjustment is necessary for patients with mild and moderate hepatic impairment; contraindicated in patients with severe hepatic impairment. It is intended for internal use only and should be disseminated only to authorized recipients. The contents of the therapeutic class overviews on this website ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Patients should always seek the advice of a physician or other qualified health provider with any questions regarding a medical condition. Clinicians should refer to the full prescribing information and published resources when making medical decisions. Aubagio (teriflunomide) Tablets Oral Once daily Drug Available Route Formulations Usual Recommended Frequency Comments Teriflunomide is contraindicated for use in pregnant women and in women of reproductive potential who are not using effective contraception because of the potential for fetal harm. Exclude pregnancy before the start of treatment with teriflunomide in females of reproductive potential and advise females of reproductive potential to use effective contraception during teriflunomide treatment and during an accelerated drug elimination procedure after teriflunomide treatment. Teriflunomide should be stopped and an accelerated drug elimination procedure used if the patient becomes pregnant. Teriflunomide is detected in human semen; to minimize any possible risk, men not wishing to father a child and their female partners should use effective contraception. Men wishing to father a child should discontinue use of teriflunomide and either undergo an accelerated elimination procedure or wait until verification that the plasma teriflunomide concentration is less than 0. Following initial administration by a trained healthcare provider, Avonex may be selfadministered. Concurrent use of analgesics and/or antipyretics on treatment days may help ameliorate flulike symptoms associated with Avonex use. It is intended for internal use only and should be disseminated only to authorized recipients. The contents of the therapeutic class overviews on this website ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Patients should always seek the advice of a physician or other qualified health provider with any questions regarding a medical condition. Clinicians should refer to the full prescribing information and published resources when making medical decisions. Drug Available Route Formulations Usual Recommended Frequency Comments Use caution in patients with hepatic dysfunction. Following initial administration by a trained healthcare provider, Glatiramer acetate may be selfadministered. First dose monitoring: Observe all patients for bradycardia for at least 6 hours; monitor pulse and blood pressure hourly.

These relationships imply nothing about the underlying polarity of the signals at inputs 1 and 2-only the polarity of their differences medicine quizlet generic dilantin 100mg line. When the name of electrode connected to input 1 is written above the deflection and the name of input 2 below, the deflection will point to the electrode with the "relative" negativity as has been done in Figure 7. If the difference between the two signals at the input is zero, no deflection will occur. When two electrodes (no matter how close to the source of the sharp wave or spike) that lie along the same isopotential line (typically at the same distance from the generator) are input to a differential amplifier, the output will reflect no activity, even though both electrodes may be measuring high amplitudes in an absolute sense. Some amplifiers used in basic neurophysiology research and in clinical evoked potentials employ another convention, designed to display positive input 1 as an upward deflection. The arrangement of derivations into a montage determines whether it is called bipolar or referential. Derivations in bipolar montages are established between neighboring electrodes to emphasize focal activity. They take advantage of the subtractive nature of differential amplifiers to effect a high degree of cancellation. Any montage can be analyzed to locate the maximum of a sharp wave or spike, provided that the montage has a logical order (6,77,78). It is convenient to link the electrodes in a systematic "chain" of bipolar derivations. Because input 1 of each succeeding channel in the montage is the same as input 2 of the preceding channel, the electrodes are all electrically linked in a structured way, and-more importantly-mathematically. Bipolar montages are of maximum advantage when attempting to pick out localized potentials, as they help to cancel out more widespread activity. Bipolar montages are most logically arranged in a longitudinal or transverse direction. In a referential montage, the same electrode is connected to input 2 of every channel, while each channel has a different electrode connected to input 1. In contrast to bipolar montages, referential montages do a better job of picking up activity that has a more widespread distribution. Derivations and Montages A derivation describes the connections of the electrodes to the amplifier inputs. Likewise, these amplifier outputs could be arranged in any fashion on the screen; the arrangement in chains assists our visual localization capabilities. It is assumed that an activity starts from "zero" and reaches its maximum after a certain time. Sometimes sharp activity can be separated from a slower background, if the frequency of the epileptic activity is clearly different, by using filtering. Identification of the baseline and peak may be particularly troublesome in the case of polyphasic discharges, in which each phase is brief and difficult to line up temporally. During visual analysis of a waveform, the montage selected will influence identification of the peak, resulting in different, or sometimes erroneous, field determinations. Multiple peaks or phase reversals with small time shifts reflect sequential change in the location of the maximum. Computerized source localization techniques are especially sensitive to the selection of the appropriate time frame. Errors in identifying the peaks that are to be mapped can cause extraordinary displacements in the apparent localization of the sources (79,80). The main component of an epileptic discharge may be preceded by a smaller deflection of the opposite polarity. Early components show a more localized field than later ones (81,82), and they are more synchronous than the slow wave that frequently follows a spike. Thus, the initial deflection probably contains more localizing information (34), and employing the lowerfrequency waves for localization may not always represent the epileptogenic region. Mapping the Electrical Field the two-dimensional display of the scalp regions involved in epileptiform or other activity is called mapping.

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In a retrospective study of 20 women with catamenial epilepsy medicine website discount 100mg dilantin, 40% reported a 50% or greater decrease in seizure frequency; the response rates were similar in generalized versus focal epilepsy and temporal versus extratemporal epilepsy (80). None of the patients (n 28) that were examined after longterm acetazolamide therapy, which ranged from 10 months to Chemistry and Mechanism of Action Acetazolamide (Diamox,4 N-(5-sulfamoyl-1,3,4-thiadiazol-2yl-)acetamide;. In the brain, acetazolamide acts through inhibition of carbonic anhydrase, causing carbon dioxide to accumulate and inducing the anticonvulsant action. Blocking carbonic anhydrase in other tissues, particularly red blood cells, causes even greater retention of carbon dioxide in the brain (71). This results in blockade of anion transport, which prevents spread of seizure activity and elevates seizure threshold. The anticonvulsant effect of acetazolamide, as measured by prevention of maximal electroshock-induced seizures (72,73), correlates with the degree of inhibition of brain carbonic anhydrase. The carbonic anhydrase inhibitory effect with subsequent increase in intracellular carbon dioxide is probably responsible for the anticonvulsant properties of acetazolamide (75). Chapter 68: Less Commonly Used Antiepileptic Drugs 785 14 years, showed evidence of renal calculi. A summary of the pharmacologic and pharmacokinetic properties, efficacy, and safety of acetazolamide in the treatment of epilepsy has been published (83). The recommended daily dosage is 10 mg/kg given in a single dose or in two or three divided doses. Usual effective therapeutic plasma levels range from 8 to 14 g/mL (conversion for acetazolamide: mol/L 4. Another recent hypothesis is that there may be an abnormality of pyridoxine transport, which underlies the pathophysiology of the disorder (98). Interactions with Other Agents and Adverse Effects Elimination of acetazolamide may decrease and the half-life of the agent may increase with the concomitant use of probenecid, which blocks renal tubular secretion of acids. The absorption of salicylate may be increased and that of amphetamine may be delayed when these drugs are taken with acetazolamide. Acetazolamide is a relatively benign agent, with only a few adverse effects known. Lethargy, paresthesias, rashes, abdominal distention, and cyanosis have been reported with its use. In up to 90% of patients, acetazolamide can alter taste sensation (84) by eliminating the tingly or prickly sensation of carbonation and giving a false flat taste to carbonated beverages; we have not seen this effect in any of our patients who had been placed on intermittent treatment. The investigators speculated that acetazolamideinduced metabolic acidosis might have been responsible for this growth suppression. Although acetazolamide use may be considered if seizures are exacerbated during pregnancy, the drug should be avoided during the first trimester. Efficacy and Clinical Use Pyridoxine Dependency the diagnosis is established by remission of seizures (generalized seizures or status epilepticus) with vitamin B6 and relapse without this treatment. Withdrawal of pyridoxine even after several years of effective therapy causes seizures to reappear within days or weeks (99,101,102). Untreated patients develop intractable epilepsy, and most die within days or months (102). Psychomotor retardation and progressive neurologic deterioration result when therapy is delayed; therefore, early diagnosis and treatment are important for stopping the seizures and preventing a chronic encephalopathy. Bass and coworkers (106) reported other atypical features in a child whose seizures stopped only after repeated trials of pyridoxine. Recommended daily oral maintenance dosages range from 2 to 300 mg, corresponding to doses from 0. These rare conditions carry a poor prognosis for mental development if prompt treatment is not rendered.

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