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Electroconvulsive therapy (ECT) is an established therapeutic method for the treatment of severe mental disorders refractory to pharmaco- and psychotherapy. ECT is a first-line treatment option in delusional disorders, severe depression with acute suicidal tendency or life-threatening catatonia. Usually, ECT is performed as a treatment series. Under short-term anaesthesia and muscle relaxation, tonic-clonic seizures are induced using an external stimulation electrode. Convulsion can be exerted by uni- or bipolar stimulation using an electric charge up to 1000 millicoulomb (mC) with an amperage of 900 mA. Muscular relaxation is necessary to prevent injuries caused by uncontrolled movements during convulsion. During paralysis, consciousness is blocked by general anaesthesia, although ECT is associated with antegrade amnesia for seizure induction and the seizure itself. In the context of ECT, the ideal hypnotic should be characterised by rapid onset, short duration of action and negligible anticonvulsive effects (i.e., least possible impact on seizure quality and duration). As mutual awareness of psychiatric and anaesthesiologic techniques is essential for safe and effective conduction of ECT, this article presents ECT both from the psychiatrist's and the anaesthesiologist's perspective., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Honorar/geldwerten Vorteil für Referententätigkeit erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: nein Erklärung zu nichtfinanziellen Interessen Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Psychogenic non-epileptic seizures (PNES) occur in the context of various diseases. Therefore, PNES patients represent a heterogeneous group with different causative disorders. The etiology is still poorly understood. Previous concepts assume an increased rate of trauma disorders in PNES, which has been proven several times by previous studies 1 2. The clinical picture is threatening, which means that those affected often receive intensive care measures without benefiting from them 3. PNES patients accumulate especially in epilepsy centers, since a diagnostic differentiation from epileptic seizures is possible at those specialized centers. Often, the transition from making the diagnosis in epilepsy centers to follow-up treatment in psychosomatic/psychiatric settings is difficult. A reason could be that patients and practitioners are often involved in somatic disease concepts, which might be caused by the threatening clinical picture of PNES 28. Due to this difficulties, a special outpatient clinic was set up at the Charité Berlin for people with dissociative seizures, which settles in the transition from neurology to psychosomatics and works as a cooperation project 27. Out of the ambulance, a group treatment program (CORDIS) was developed, which aims at a better care of PNES patients at the interface between neurology and psychosomatic medicine. This modularized 10-week treatment program will be presented in this article and is the subject of a currently ongoing randomized, controlled evaluation study. The pilot data from the ongoing RCT study presented here showed significant effects in the effectiveness of the program, in particular the primary and secondary outcome measures., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Epilepsy is a frequent and disabling neurological disease with a significant burden for patients and their relatives worldwide. Epileptogenesis is understood as the plastic process that after an insult (in acquired epilepsies) finally leads to seizures with a latent period. In some cases, epileptogenesis has been clarified down to the molecular level. In parallel, the discovery of genetic defects has decisively contributed to unravel epileptic disease mechanisms. Both research directions have enabled first personalized treatment options. In addition, genetic variants associated with epilepsy can not only directly cause seizures but likely also induce an epileptogenic process (similar as in acquired epilepsies) and interact with developmental processes of the brain, finally leading to the typical age-dependent manifestation of genetic epilepsy syndromes. This article describes these correlations and the consequences for personalized treatment possibilities.

Suspected epileptic seizures are a frequent cause of emergency hospital care. After single seizures, the emergency management includes safety measures and diagnostic efforts to distinguish epileptic seizures from its manifold mimics and to possibly detect acute causes of epileptic seizures. Convulsive status epilepticus requires rapid anticonvulsant treatment according to established protocols and diagnostics to rule out underlying acute brain diseases. After a first seizure, typical EEG- and MRI findings may indicate an elevated recurrence risk, thereby justifying the ultimate diagnosis of epilepsy and initiation of anticonvulsant therapy. This article reviews the recent definition of epilepsy, summarizes clinical characteristics of epileptic seizures and its mimics and provides an overview of established therapies of single convulsive seizures, convulsive status epilepticus and early care of adults after first unprovoked seizures., Competing Interests: Rainer Surges hat in den letzten 5 Jahren Honorare für Vorträge oder als Berater von Bial, Cyberonics, Desitin, Eisai, LivaNova, Novartis und UCB Pharma erhalten.Johannes Schiefer gibt an, keine Interessenkonflikte zu haben., (© Georg Thieme Verlag KG Stuttgart · New York.)

Perspectives for the Electroencephalogram in Psychiatry Abstract. The electroencephalogram (EEG) is a non-invasive and cost-effective method to monitor spontaneous neuronal activity over time. Pathologies in EEG recordings indicate with high sensitivity but low specificity abnormal functional brain states. The main psychiatric indications for EEG recordings include atypical clinical symptoms of a neuropsychiatric syndrome or atypical reactions to medication as well as a baseline diagnostic before starting treatment with specific drugs or stimulation modalities. In recent research the EEG continues to be a valuable tool not only in diagnostics but also for the prediction of treatment success. The following paper focuses on basic electrophysiological understanding of EEG recordings, the diagnostic value of EEG recordings in different clinical entities, and new research attempts in diagnostic and treatment prediction.

Status epilepticus is a neurologic emergency manifested by prolonged seizure activity or multiple seizures without full recovery of previous condition in between. The most important aim of treatment is early seizure termination, because duration of status epilepticus correlates with a higher rate of morbidity and mortality. Based on evidence from clinical trials and guidelines strategies for management of status epilepticus are provided., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Patient history taking and semiology provide seminal clues to the diagnosis of dissociative seizures. Openness and alertness of the treating physician are essential. Video-electroencephalogram(EEG)-based analyses of the events are crucial to establish the correct diagnosis, particularly in complex cases. The patient-doctor relationship is of particular importance in order to successfully motivate the patient for psychotherapeutic treatment. Coexisting psychiatric morbidity as well as other functional somatic symptoms must be actively explored. Current changes in the established diagnostic manuals, including ICD-11, reflect the ongoing vivid interest and controversial discussions in the field of dissociative disorders.

Short involuntary paroxysmal movements or behavioral patterns are an important differential diagnosis to epileptic seizures, especially when occurring for the first time. Typically, these attacks are not witnessed by medically trained personnel and the patient anamnesis or observations by a third party are often not specific enough to differentiate between epileptic seizures and the differential diagnoses. This review presents the epidemiology, the clinical presentation, the necessary diagnostic steps and the differential diagnostic approach to parasomnias and dyskinesias. The focus is on the clinical aspects, and therapeutic principles are also briefly described.

Following stroke, 3-6% of patients develop acute symptomatic seizures within the first 7 days. The rate is higher after cerebral haemorrhage compared to ischaemia. In 10-12% of patients, after more than 7 days unprovoked seizures occur. Due to these low incidence rates, primary prophylaxis with antiepileptic drugs is generally not necessary. Following one acute symptomatic seizure, recurrence risk within the first 7 days post-stroke is 10-20%, generally arguing against secondary prophylaxis with an antiepileptic drug. In clinical practice however, antiepileptic drug treatment in this constellation is often initiated. If this is done, the antiepileptic drug should be withdrawn soon after the acute phase, as the long-term risk for manifestation of an unprovoked seizure is approximately 30%. Following one post-stroke unprovoked seizure, recurrence risk within the next 10 years is more than 70%, this defines epilepsy. In this case, antiepileptic drug treatment is regularly recommended.

Introduction: For alcohol withdrawal during hospitalization, often a medication as means for withdrawal needs to be chosen. Modern, score-controlled processes that can be used by the nursing staff after instruction by physicians are frequently not used and even unknown in hospitals. One reason for this is that some of the scores require checking several criteria and are therefore more time-consuming and complicated than use of a fixed-dosage strategy. The SAB-P and HAES are short with only 6 items that can be checked by the nursing staff., Methods: Safety of the Hamburg Alcohol Withdrawal Scale (Hamburger Alkoholentzugs-Skala (HAES)) was analyzed retrospectively and prospectively with regard to score-controlled alcohol-withdrawal treatment after rating by the nurse staff (Scoregesteuerte Alkoholentzugsbehandlung nach Rating durch das Pflegepersonal (SAB-P))., Results: Incidence of complications in patients treated with SAB-P and HAES was nearly similar with 1% start of delirium and 3% seizures (SAB-P) and 0.5 to 1.5% start of delirium and 0 to 0.5% seizures in the HAES group. With both scales it was possible to start medical treatment while still under falling alcohol levels (0.93 and 0.91%, respectively). Medication dosage was initially higher using the HAES, so that the time needed to monitor withdrawal symptoms could be reduced (3.8 vs. 3.1 days)., Discussion: Using a score-controlled strategy for alcohol withdrawal leads to a lower complication rate than found in literature. The structured procedure was helpful for the nursing staff as well as for the physicians. SAB-P as well as HAES made withdrawal for the patients more comfortable and led to fewer complaints. Because of rapid reaction and faster symptom reduction of HAES, there was less time necessary for monitoring. Simple handling, clomethiazol, oxazepam or diazepam as applicable medication and clear documentation are the advantages of HAES., (© Georg Thieme Verlag KG Stuttgart · New York.)

Psychogenic non-epileptic seizures (PNES) are one of the most important differential diagnoses of epileptic seizures and represent a challenging pathology for clinicians. The aim of this article is to impart clinical criteria for an accurate diagnosis of psychogenic non-epileptic seizures since an early and appropriate treatment may considerably improve the prognosis., (© Georg Thieme Verlag KG Stuttgart · New York.)

The great physical resemblance between epileptic and dissociative seizures and a diagnosis of epilepsy that had been made years ago and usually had been treated unsuccessfully makes it difficult for both physician and patient to communicate the diagnosis of dissociative seizures. A direct referral to psychotherapy treatment is rarely accepted by patients. Intermediate steps, which are based on cooperation between neurologists and psychotherapists, are necessary. The approach that we use to communicate diagnosis and motivation for psychotherapeutic treatment includes eight steps: 1. Welcome and introduction; 2. Jointly watching a video of documented seizures; 3. The message that the seizures are not of epileptic origin, 4. Development of an alternative disease concept; 5. Motivation for a conversation with a representative from psychosomatics; 6. Responding to the fear of "going crazy"; 7. If necessary, briefly touching on the subject of sexual violence; 8. More recommendations and conclusion of the conversation. The manual was discussed and practiced with the attending neurologist in two sessions and is now being regularly used by two neurologists with concomitant supervision.

Dissociative seizures, albeit a psychiatric symptom, are encountered only rarely in psychiatric settings and more often in a neurologic context. Due to the clinical similarity of these dissociative states with neurological symptoms, optimal treatment is often hampered and lies on the border between psychiatric and neurologic approaches. Diagnostic work-up as well as the therapy may prove to be complex and tedious, partly due to the underlying psychopathology of these patients. Management by neurologists, psychiatrists, and primary care physicians should take into account specific therapeutic and diagnostic guidelines aimed at improving outcome and minimizing the negative social and occupational effect which often burden these patients.

We report about a 3-day-old full-term newborn who suffered from series of tonic-clonic and myoclonic seizures. His mother was treated with lamotrigin for epilepsy. It is worthy of note that the drug level of the neonate had already decreas-ed to 37% of the basic level of his mother. At the same time, there was a catabolic metabolic situation and a mild hyponatriaemia. We believe that the neonatal seizures were caused by lamotrigin withdrawal.

Whole body hypothermia can be used to treat the injured brain (e.g. after hypoxic events). Side effects include hemodynamic instability, coagulopathy and infection. Because of these side effects it appears reasonable to cool the brain selectively (selective brain cooling, SBC) without changing the core temperature. A new animal model was used to demonstrate SBC from the pharynx and to examine effects of SBC on the duration of pharmacologically induced seizure activity. Sprague-Dawley rats (n=18, 12 successful experiments) were sedated and mechanically ventilated. Invasive blood pressure monitoring was instituted and blood gases were drawn to evaluate the arterial blood gas status. Electrical brain activity was recorded using a microneedle in the extracellular compartment of the rat brain cortex. Cooled water was circulated through a small tubing into and out of the pharynx of the animals. The cortical as well as the rectal temperature were recorded. After the injection of a single dose of bicuculline (1 mg/kg i.v.) per animal the duration of the induced seizure activity was measured and compared with the temperature prior to the induction of seizure activity. The cortical blood flow (CBF) was detected using intra tissue Doppler signals in the rat cortex in the same location as the EP-study. The influence of a brain temperature reduction between 36.5 degrees to 31.5 degrees C on the seizure duration was examined. There was a positive correlation between the seizure duration and the cortical temperature (r=0.64). Also the CBF was increased during seizure activity (p=0.02) and the increase correlated weakly with cortical temperature (r=0.18). The core temperature remained in the normothermic range (36.9+/-0.7 degrees C) Conclusion: The duration of induced seizures correlates with local brain temperature. In the future further studies should examine the efficiency of induced (selective) brain cooling to treat prolonged seizure activity.

Attempts to control epileptic seizures by electrical brain stimulation have been performed for 50 years. Many different stimulation targets and methods have been investigated. Vagal nerve stimulation (VNS) is now approved for the treatment of refractory epilepsies by several governmental authorities in Europe and North America. However, it is mainly used as a palliative method when patients do not respond to medical treatment and epilepsy surgery is not possible. Numerous studies of the effect of deep brain stimulation (DBS) on epileptic seizures have been performed and almost invariably report remarkable success. However, a limited number of controlled studies failed to show a significant effect. Repetitive transcranial magnetic stimulation (rTMS) also was effective in open studies, and controlled studies are now being carried out. In addition, several uncontrolled reports describe successful treatment of refractory status epilepticus with electroconvulsive therapy (ECT). In summary, with the targets and stimulation parameters investigated so far, the effects of electrical brain stimulation on seizure frequency have been moderate at best. In the animal laboratory, we are now testing high-intensity, low-frequency stimulation of white matter tracts directly connected to the epileptogenic zone (e.g., fornix, corpus callosum) as a new methodology to increase the efficacy of DBS ("overdrive method").

Neurocardiogenic convulsive syncope as a disease at the border between cardiovascular and neurologic dysfunction can pose considerable diagnostic challenges. We report on the case of a 19 year-old female patient with recurrent neurocardiogenic convulsive syncope where the time from the onset of symptoms to the correct diagnosis and initiation of an effective therapy spanned more than three years. Based on this case report, we discuss differential diagnosis, pathophysiology and therapy of this disorder of autonomic cardiovascular regulation. Neurocardiogenic convulsive syncope should be considered whenever a patient has both syncope that exhibits a typical cardiovascular pattern (e.g., fainting of short duration with rapid reorientation phase) and prolonged loss of consciousness with characteristic neurological features (e.g., cerebral seizures with postictal state of confusion). Head-up tilt testing, introduced into clinical practice in 1986, is an efficient tool to diagnose neurocardiogenic syncope with comparatively high sensitivity in patients with recurrent syncope of unknown origin. Besides orthostatic training and pharmacotherapy, permanent dual-chamber cardiac pacing has gained increasing importance as treatment for cardioinhibitory forms of neurocardiogenic syncope.

History and Clinical Findings: A 67-year-old man with known bronchial asthma was admitted to hospital because of deteriorating general state of health, fever, progressive renal failure and confusional states., Investigations: Erythrocyte sedimentation rate was 70/95 mm and the concentration of C-reactive protein raised to 30 mg/dl. WBC count was 19,000/microliter with 39% eosinophilia. Anticytoplasmatic antibodies (cANCA) had a high titre (1:160). On admission the creatinine level was 5.6 mg/dl. Renal biopsy indicated marked glomerular and tubulo-interstitial scarring. Chest radiograms showed transient pulmonary infiltrates. Churg-Strauss syndrome (CSS) was diagnosed on the basis of the clinical and biochemical findings., Treatment and Course: Haemodialysis was instituted to counteract the renal failure with water retention. Inflammatory parameters and clinical symptoms rapidly responded to administration of corticosteroids (prednisolone, initially 250 mg/d for 3 days, then 150 mg/d for 5 days followed by slowly decreasing doses). Two weeks after starting prednisolone he had secondary generalised seizures. Magnetic resonance imaging (MRI) of the skull demonstrated marked hyperintense focal changes which in their pattern were characteristic of cerebral vasculitis. As a steroid-refractory condition had to be assumed, cyclophosphamide was also given (100 mg/d). Within 6 weeks the clinical symptoms gradually regressed and the MRI changes became practically normal., Conclusion: Early combined immunotherapy should be given if CSS runs a complicated course, rather than the usually recommended corticosteroid monotherapy.

The neuropaediatric emergency can be considered according to 1. The primary symptom, single or combined or 2. The diagnosed disease as a whole. Primary combined symptoms are: 1. Disturbance of Consciousness, fever, emesis, skin bleeding (inflammation). 2. Disturbance of consciousness, emesis, normal temperature, stretched fontanel (brain pressure). 3. Disturbance of consciousness, seizure disorder, normal temperature (epileptic fit). 4. Disturbance of consciousness, seizure disorder, fever (febrile seizure). 5. Disturbance of consciousness, bruise marks, normal temperature, accident (skull-cerebral trauma) Procedure used by the physician: 1. Avoidance of additional sequelae (aspiration, injury). 2. Protection of vital functions. 3. Ascertainment of causes. 4. Creating an intravenous access. 5. Drug therapy. 6. If necessary, intubation and respiration. 7. Transport to hospital

330 out of 616 surviving newborns treated in the neonatal ICU of Berne University Children's Hospital from 1.1 1974 to 31.12. 1976 were considered, on the basis of strict criteria, to be especially at risk for the development of abnormal cerebromotor symptoms, 287 were followed up. At age 3--42 (mean 15) months, 10% of these especially endangered children showed clear-cut, and 24% slightly abnormal, symptoms. If related to the total number of surviving patients, all of whom were either ill or at risk for disturbed neonatal adaptation, this corresponds to 5 and 11% respectively. Based on this population, an approximate incidence of cerebral palsy of 5% at age 15 months can be calculated for the whole pediatric population. This value is comparable to the 2% actually found in the total pediatric population. Furthermore, a statistically significant decrease in abnormal symptoms with increasing postnatal age was found. Newborns with convulsions, however, do not have this favourable prognosis.

The immediate management of three kinds of emergencies in childhood-unconsciousness, convulsions and acute respiratory failure-is discussed. First of all and in any case it is necessary to assess and reestablish vital, especially cardiorespiratory functions. Most common causes of unconsciousness in young children are dehydration states and acute poisoning, followed by febrile convulsions. Differential diagnosis and first management of subglottic laryngitis and peracute epiglottitis, two severe acute respiratory failures in childhood, are also demonstrated.

From neurological point of view some important acute situations are discussed. These are: seizures, radicular pain attacks, headache-attacks, stroke, impaired consciousness of uncertain origin. The two main criteria of acuity, i.e.: dramatic and dangerous, will combine in many cases, but dissociate sometimes. This has to be considered especially in those cases where acute danger exists although a dramatic picture is missing, for example in subarachnoid hemorrhage with poor symptomatology and in pareses or cross section syndromes without pain. The primary contacted physician is able to contribute a great deal to further diagnosis and treatment through exact primary observation which is important in acute syndromes because of their tendency to change rapidly and to present under different features when the patient arrives in hospital. This concerns above all: differentiation of seizures, differentiation of stroke and differentiation of impaired consciousness. Besides the primary dramatic situation and acute therapy it is important not to neglect the necessity of further diagnostic particularly in seizure patients who recover quickly after the acute situation but nevertheless need to be brought to sufficient diagnostic and treatment.