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Objective To provide national guidelines for the management of women with severe pre-eclampsia. Design A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE(r)) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Methods The last SFAR and CNGOF guidelines on the management of women with severe pre-eclampsia were published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE(r) methodology. Results The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1+/−), 9 have a moderate level of evidence (GRADE 2+/−), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. Conclusions There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe pre-eclampsia.

Objective To provide national guidelines for the management of women with severe pre-eclampsia. Design A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Methods The last SFAR and CNGOF guidelines on the management of women with severe pre-eclampsia were published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE® methodology. Results The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1+/−), 9 have a moderate level of evidence (GRADE 2+/−), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. Conclusions There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe pre-eclampsia.

Objectives Several studies have shown that bilateral abolition of somatosensory evoked potentials after a nontraumatic coma has 100% specificity for nonawakening with ethical consequences for active care withdrawal. We propose to evaluate the prognostic value of bilateral abolished cortical components of SEPs in severe vascular coma. Methods A total of 144 comatose patients after subarachnoid haemorrhage were evaluated by multimodal evoked potentials (EPs); 7 patients presented a bilateral abolition of somatosensory and auditory EPs. Their prognosis value was interpreted with respect to brainstem auditory EPs, EEG, and structural imaging. Results One patient emerged from vegetative state during follow-up; 6 patients did not return to consciousness. The main neurophysiological difference was a cortical reactivity to pain preserved in the patient who returned to consciousness. This patient had focal sub-cortical lesions, which could explain the abolition of primary cortical components by a bilateral deafferentation of somatosensory and auditory pathways. Conclusions This is the first report of a favourable outcome after a multimodal abolition of primary cortex EPs in vascular coma. For the 3 cases of vascular coma with preserved brainstem function, EEG reactivity and cortical EPs were abolished by a diffuse ischaemia close to cerebral anoxia. Significance The complementarity of EPs, EEG, and imaging must be emphasised if therapeutic limitations are considered to avoid over-interpretation of the prognosis value of EPs.

Cancer risk assessment is performed generally in relation to assessment of the safety of new medical products or environmental exposures, especially when DNA modification is a factor. The risk assessment paradigms used for products subject to regulatory review are independent of specific cancers, multiple exposures, and individual risk factors. A default cancer risk assessment for regulatory review includes “uncertainty factors” to account for differential susceptibility and other variables involved in extrapolating from experimental systems to human risk. However, there is a growing amount of evidence that suggests differing risk for different types of cancer as well as the importance of combinations of risk factors not limited to genetic or environmental effects. In the era of personalized medicine and cancer genomics, can we begin to assess personalized cancer risk, instead of overall cancer risk? What models would assist in this paradigm shift? There are several cancers for which specific genetic, environmental, viral and other associations have been established and could be used in personalized cancer risk assessments, including colon, liver, and lung cancer. A search was conducted on PubMed for available literature on epidemiology, genetic susceptibility, and risk factors associated with the major types of cancer, including ~25 pathological types of cancer in 17 different organs. Risk factors associated with each included chemical exposures and tobacco, as well as genetic, epigenetic, microbial, viral, dietary, exercise, and other factors known for involvement in the development of cancer in humans. The diversity of cancers and evidence for specific risk factors is summarized. Common risk factors, including smoking and obesity, are supplemented with a substantial set of individual, often non-overlapping risk factors for diverse cancers. Surprisingly, little evidence was found that genetic-environmental interactions are significant risk factors for most cancers. From this assessment we can begin to ask whether and for what cancers a personalized risk approach seems feasible. Disclaimer: The findings and conclusions in this presentation are those of the authors and should not be construed to represent any agency determination or policy. Citation Format: Rosalie K. Elespuru, Catherine Fischer. Personalized cancer risk and prevention: analysis of risk factors for specific cancers and integration into cancer risk assessment paradigms [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2612.

An unsexed, 16-year-old blue-and-gold macaw (Ara ararauna) was presented for evaluation of rapidly growing subcutaneous masses at the left tibiotarso-tarsometatarsal joint. Results of incisional biopsy were diagnostic for an intermediate-grade soft-tissue sarcoma. A distal-femoral amputation was performed and the leg was submitted for histopathology. Histopathologic examination confirmed the biopsy diagnosis and revealed neoplastic spread into the bone marrow cavity of the tibiotarsus. Excisional margins were complete. The macaw recovered and did well until it died suddenly 32 months after surgery. At necropsy, death was attributed to acute hepatic hemorrhage. No recurrence or metastasis of the sarcoma was identified.

Aims Several high-sensitivity cardiac troponin (hs-cTn) assays have recently been developed. It is unknown which hs-cTn provides the most accurate prognostic information and to what extent early changes in hs-cTn predict mortality. Methods and results In a prospective, international multicentre study, cTn was simultaneously measured with three novel [high-sensitivity cardiac Troponin T (hs-cTnT), Roche Diagnostics; hs-cTnI, Beckman-Coulter; hs-cTnI, Siemens] and a conventional assay (cTnT, Roche Diagnostics) in a blinded fashion in 1117 unselected patients with acute chest pain. Patients were followed up 2 years regarding mortality. Eighty-two (7.3%) patients died during the follow-up. The 2-year prognostic accuracy of hs-cTn was most accurate for hs-cTnT [area under the receivers operating characteristic curve (AUC) 0.78 (95% CI: 0.73–0.83) and outperformed both hs-cTnI (Beckman-Coulter, 0.71 (95% CI: 0.65–0.77; P = 0.001 for comparison), hs-cTnI (Siemens) 0.70 (95% CI: 0.64–0.76; P < 0.001 for comparison)] and cTnT 0.67 (95% CI: 0.61–0.74; P < 0.001 for comparison). Absolute changes of hs-cTnT were more accurate than relative changes in predicting mortality, but inferior to presentation values of hs-cTnT. Combining changes of hs-cTnT within the first 6 h with their presentation values did not further improve prognostic accuracy. Similar results were obtained for both hs-cTnI assays regarding the incremental value of changes. Hs-cTn concentrations remained predictors of death in clinically challenging subgroups such as patients with pre-existing coronary artery disease, impaired renal function, and patients older than 75 years. Conclusion High-sensitivity cardiac Troponin T is more accurate than hs-cTnI in the prediction of long-term mortality. Changes of hs-cTn do not seem to further improve risk stratification beyond initial presentation values.

Resume La thrombopenie gestationnelle concerne environ 10 % des femmes enceintes. Dans 75 % des cas, il s’agit d’une thrombopenie gestationnelle benigne, sans consequence et sans risque hemorragique. Cependant, elle peut reveler des pathologies graves comme la preeclampsie, le hemolysis elevated liver enzyme and low platelets (HELLP) syndrome et les redoutables microangiopathies thrombotiques. Elle peut aussi s’inscrire dans le cadre d’un purpura thrombopenique auto-immun ou d’une autre affection auto-immune comme le lupus ou le syndrome des anticorps antiphospholipides. Le risque hemorragique et les consequences fœtomaternels sont variables en fonction de ces pathologies, ce qui impose un diagnostic etiologique precis. Les examens complementaires ne sont pas systematiques et doivent etre orientes en fonction des signes associes. Le diagnostic differentiel entre purpura thrombopenique auto-immun et thrombopenie gestationnelle n’est pas biologique, mais clinique et anamnestique. La strategie therapeutique et l’attitude vis-a-vis de la realisation de l’anesthesie/analgesie locoregionale est fonction de chaque pathologie.

Resume Les infections severes sont rares au cours de la grossesse ou en postpartum, malgre une forte incidence de bacteriemies chez les femmes enceintes. Les germes les plus souvent en cause sont l’ Escherichia coli et le streptocoque B, mais les infections sont souvent polymicrobiennes. Une recrudescence des infections graves a streptocoque A est responsable d’une augmentation recente de la part relative des infections impliquees dans la mortalite maternelle des pays industrialises. Le statut physiologique et la faible incidence des comorbidites expliquent la rarete du choc septique chez la femme enceinte ; en l’absence de donnees specifiques au cours de la grossesse, la prise en charge initiale s’appuie sur les principes de reanimation precoce en tenant compte des modifications hemodynamiques et pulmonaires, responsables notamment d’une defaillance respiratoire. L’antibiotherapie a large spectre doit etre ultraprecoce. L’extraction fœtale peut etre indiquee pour des motifs obstetricaux mais ne modifie pas le pronostic maternel, excepte en cas d’arret cardiorespiratoire.

Case Description—A 5-year-old spayed female cat was evaluated because of lethargy of 3 days' duration, acute respiratory distress, and anemia. Clinical Findings—Physical examination revealed the cat was in good body condition but had pale mucous membranes and elevated heart and respiratory rates. Results of hematologic analysis indicated the cat had severe anemia (Hct, 0.07 L/L; reference range, 0.28 to 0.49 L/L) and marked rubricytosis (19.0 × 109 cells/L; reference value, 0 cells/L). Results of serologic and PCR assays for detection of FeLV and FIV and PCR assays for detection of Mycoplasma spp were negative. Cytologic evaluation of a bone marrow aspirate and histologic evaluation of a biopsy specimen revealed a predominance of rubriblasts and rubricytes with granulocytopenia. Cytologic evaluation of fine-needle aspirates of the spleen and liver also revealed numerous rubriblasts. Treatment and Outcome—The cat received transfusions of packed RBCs, and supportive treatment was administered. Analysis of test results yielded a diagnosis of acute myeloid leukemia (erythroid subtype). Because of continued hemolysis and anemia in combination with the diagnosis of erythroleukemia (which has a poor prognosis), the cat was euthanized. Clinical Relevance—To the authors' knowledge, erythroleukemia has only been reported in cats infected with FeLV. However, results of all diagnostic assays for FeLV were negative in the cat reported here, which suggested that erythroleukemia can develop in cats in the absence of FeLV infection.

Objective To assess markers of cognition, if any, in patients in a permanent vegetative state (PVS). Methods Event-related potential (ERP) mapping was performed on 27 patients in permanent (4–261 months after coma onset) vegetative (PVS, n = 16) or minimally conscious states (MCS, n = 11) due to anoxia ( n = 18) or other aetiologies ( n = 9). Mismatch negativity (MMN) to duration-deviant tones and novelty P3 (nP3) to the subject’s own name were recorded according to a paradigm previously validated in healthy volunteers and comatose patients. SEPs, MLAEPs and BAEPs were also recorded. Results MMN was present in 5/27 and nP3 in 7/27 patients. ERPs were not related to the time from coma onset and not different in MCS and in PVS. Normal SEPs and MLAEPs, and present nP3s were less frequent in anoxia than in other aetiologies. Conclusions Irrespective of their clinical assessment, a few patients are likely to process sound deviance (MMN) or novelty (nP3), mainly when their state is not due to anoxia. Significance Some PVS patients may be able to put certain awareness marker processes to work. The diagnostic criteria for PVS or MCS, currently based on mere behaviour, should also include functional brain investigations, such as ERPs, related to the aetiology.

Summary Purpose Indication of gamma-knife surgery (GKS) in temporal lobe epilepsy (TLE) remains a matter of debate. Either positive or negative results have been reported in studies with a maximum follow-up of 24 months. No long-term data have been published yet. Methods We collected data from 15 TLE patients who underwent GKS and whose follow-up was longer than 24 months. Localisation and extension of the epileptogenic zone (EZ) were assessed by SEEG in eight patients. Ten patients were presenting with mesial TLE (mTLE) while in the other five SEEG showed that the EZ was extending beyond mesio-temporal structures. GKS procedure was targeted to the EZ at a dose of 21.1 ± 2.6 Gy at the margin. Results The mean duration of the follow-up was 60 ± 22.3 months. At last follow-up, seven patients (46.7%) were free of disabling seizure. The last seizure following GKS occurred on average after a delay of 19.75 ± 20.62 months. No patient suffered recurrent seizures after a long period free of disabling seizures. No significant prognostic predictor could be individualized in this population. However, 6 of the 10 patients with mTLE (60%) were seizure free whereas only 1 of the 5 (20%) whose EZ was more extended exhibited the same seizure outcome. Conclusion When a positive outcome is achieved, the risk of seizure recurrence remains low at long term. In patients with typical mTLE, long-term GKS results may be closed to those observed after conventional surgery. Conversely, this procedure should not be proposed to patients in whom SEEG results suggest that the EZ is not restricted to mesial temporal structures.

Vagus Nerve Stimulation (VNS) is recognized as an efficient procedure for controlling seizures in patients with drug-refractory epilepsies. It is used as a palliative procedure as a complement to conventional treatment by antiepileptic (AE) drugs and, according to literature, 40 to 50p.cent of patients report a decrease in seizures frequency >or=50p.cent, which is usually accepted to classify patients as responders in add on AE drug trials. The objectives of this study based on retrospective analysis of 50 consecutive patients with partial (39) or generalized (11) refractory epilepsy non eligible for surgery were; firstly to evaluate the global long term VNS efficacy and secondly to identify potential predictors of the VNS effects on seizure frequency. No patient has been seizure free at any moment of the follow up (2.8+/-1.8 years, max: 6 years) and the AE has been maintained in all. During follow up 44, 66, 61 and 58p.cent of patients were classified as responders at 6 months, 1, 2 and 3 years, respectively. Logistic regression analysis showed that: the percentage of responders at 6 months of follow up and later was significantly higher than that before 6 months (p=0.002); generalized epilepsy was predictive of a better outcome as compared to partial epilepsy (p=0.03); there was a trend for a better outcome in partial epilepsies symptomatic of a focal lesion than in those with normal brain MRI (p=0.06). These results are in line with previously published data in terms of global efficiency and confirm that seizures control does not reach its maximal level before at least one year of VNS. In severe generalized epilepsies (either secondary or cryptogenic) manifesting by frequent falls due to atonic or tonic-clonic generalized seizures VNS is a useful palliative procedure, which entails much les of surgical risk than callosotomy. The better VNS effects in patients with partial epilepsy possibly reflect the high incidence in our series of Malformations of Cortical Development, which have been identified as one the few variables possibly predictive of a response over 50p.cent of seizures frequency reduction.

To evaluate the utility of sensory and event-related evoked potentials for the prediction of awakening/nonawakening in severe anoxic coma and to design a decision tree helping decision for any patient in this condition.Prospective cohort study.Clinical neurophysiology unit and intensive care unit of a French university hospital.Sixty-two consecutive severe comatose patients after out-of-hospital cardiac arrest.None.We gathered clinical variables and recorded the somatosensory, auditory, and cognitive evoked potentials within an average period of 8 days after cardiac arrest. The patients were followed for 12 months and classified as awake or nonawake (permanent vegetative state or death). The statistical study included measurements of specificity, sensitivity, and positive and negative predictive value for each clinical and electrophysiologic variable recorded at the early stage of coma. Furthermore, a tree-based classification analysis was performed.All patients in whom somatosensory evoked potentials or middle-latency auditory evoked potentials were abolished did not awaken (100% specificity). All patients in whom mismatch negativity (MMN) was present awakened (100% specificity). MMN was superior to somatosensory evoked potentials for the prediction of awakening and had the best specificity and positive predictive value for awakening. On the decision tree, the awakening/nonawakening explicative variables were, by order of importance, MMN, pupillary reactivity, and somatosensory evoked potentials.There is a need to predict early and accurately awakening or nonawakening in postanoxic comas. Using sensory and cognitive evoked potentials to assess the functional condition of the brain, a prognostic tree for the prediction of awakening/nonawakening in severe anoxic coma has been designed. It is applicable to any patient in this condition and offers the possibility to predict with very high probability awakening when MMN, the earliest component of event-related potentials, is present and nonawakening when MMN and pupillary light reflex are absent or cortical components of somatosensory evoked potentials are abolished.

Hearing one's own first name automatically elicits a robust electrophysiological response, even in conditions of reduced consciousness like sleep. In a search for objective clues to superior cognitive functions in comatose patients, we looked for an optimal auditory stimulation paradigm mobilizing a large population of neurons. Our hypothesis was that wider ERPs would be obtained in response to the subject's own name (SON) when a familiar person uttered it. In 15 healthy awake volunteers, we tested a passive oddball paradigm with three different novels presented with the same probability (P = 0.02) : SON uttered by a familiar voice (FV) or by an unknown voice (NFV) and a non-vocal stimulus (NV) which preserved most of the physical characteristics of SON FV. ERP (32 electrodes) and scalp current density (SCD) maps were analyzed. SON appeared to generate more robust responses related to involuntary attention switching (MMN/N2b, novelty P3) than NV. When uttered by a familiar person, the SON elicited larger response amplitudes in the late phase of novelty P3 (after 300 ms). Most important differences were found in the late slow waves where two components could be temporally and spatially dissociated. A larger parietal component for FV than for NFV suggested deeper high-level processing, even if the subjects were not required to explicitly differentiate or recognize the voices. This passive protocol could therefore provide a valuable tool for clinicians to test residual superior cognitive functions in uncooperative patients.

Objective To assess pre-attentive detection mechanisms indexed by MMN component of auditory Event-Related Potentials (ERPs) in Multiple Sclerosis (MS) patients. Methods 46 MS patients (mean age 43.7 years, mean disease duration 10.1 years, mean EDSS 4.6) and 46 matched controls were assessed with ERPs elicited by a passive oddball paradigm using duration deviants. Auditory P50, N1, P2 components were recorded. MMN and P3a components were calculated as the difference potential between deviants and standard stimuli. Eighteen of these 46 patients underwent also global psychometrical assessment and were sorted in cognitively normal and impaired patients. ERPs of these two groups of patients were compared. Results MS patients showed reduced MMN and P3a areas as compared to controls, besides exogenous N1–P2 complex amplitude reduction. Among the 18 patients investigated with neuropsychological testings, six were cognitively impaired and 12 cognitively unimpaired. Patients with a global cognitive impairment had reduced MMN as compared to cognitively unimpaired patients. Conclusions Auditory MMN and P3a components of auditory ERPs are altered in MS patients. MMN alterations are more pronounced in cognitively impaired patients. Significance MMN and P3a areas reduction suggests that MS patients are prone to pre-attentive auditory information processing deficits, besides previously described controlled information processing difficulties. Moreover, MMN alterations may represent an objective index of cognitive disturbances in MS patients.

We studied the surgical outcome, and the complications in a group of 100 consecutive adult patients with medically refractory epilepsy arising from the temporo-mesial structures.Hundred patients were treated surgically between 1994 and 2003 for drug-resistant epilepsy involving the temporo-mesial structures. All of them underwent a comprehensive noninvasive presurgical evaluation. Fourty-eight of them underwent depth electrodes recordings (according to the Talairach's StereoElectroEncephaloGraphic (SEEG) methodology) because the noninvasive investigations were not congruent enough to identify the epileptic zone. The patients presenting with any space-occupying lesion, or with a cavernoma, or with a strictly lateral neocortical epileptic focus, were excluded. The MRI-examination was abnormal in 87 cases, displaying a hippocampal atrophy in 69 cases. The extent of temporal resection was planned according to the results of the presurgical investigation in each particular patient. Consequently, this "tailored" resection varied from selective amygdalo-hippocampectomy (6 cases), to anterior temporal lobectomy (76 cases), or to total temporal lobectomy (18 cases).The mean post-operative follow-up period was 53 months. 85 patients were found to be in Engel's class I post-operatively (free of disabling seizures), among them 74 were in class Ia (totally seizure free). Nine patients were in Engel's class II and six were in Engel's class III or IV (failures). There was no surgical mortality. Three patients had a postoperative hematoma; two patients required a shunt insertion; in three patients meningitis occurred; and two patients had postoperative ischaemia of the anterior choroidal artery territory, which resulted in a mild permanent hemiparesis. Neuropsychological complications are not addressed in detail in this article.These data indicate that "tailored" resective surgery for temporo-mesial epilepsy can be performed with a low rate of morbidity, and is highly efficacious. The use of invasive presurgical investigation (SEEG) may explain this high rate of success.

While source localization methods are increasingly developed to identify brain areas underlying scalp electro/magnetoencephalographic data (EEG/MEG), these methods have not yet been used to identify the sources of intracerebral signals which offer highly detailed information. Here, we adapted the minimum current estimates method to intracranial data in order to localize supratemporal sources of intracerebral auditory 1-kHz-tone-evoked potentials occurring within 100 ms after stimulus onset. After an evaluation of localization method and despite inter-subject variability, we found a common spatiotemporal pattern of activities, which involved the first Heschl's gyrus (H1) and sulcus (HS), the Planum Temporale (PT), H2/H3 when present, and the superior temporal gyrus (STG). Four time periods of activity were distinguished, corresponding to the time range of the scalp components P0, Na, Pa/Pb, and N100. The sources of the earliest components P0 (16–19 ms) and Na (20–25 ms) could be identified in the postero-medial portion of HS or H1. Then, several areas became simultaneously active after 25 ms. The Pa/Pb time range (30–50 ms) was characterized by a medio-lateral and postero-anterior propagation of activity over the supratemporal plane involving successively H1/HS, the Planum Temporale, H2/H3 when present, and the STG. Finally, we found to a large extent that the N100 (55–100 ms) involved almost the same areas as those active during the Pa/Pb complex, with a similar propagation of activities. Reconstructing scalp data from these sources on fictive EEG/MEG channels reproduced classical auditory evoked waveforms and topographies. In conclusion, the spatiotemporal pattern of activation of supratemporal auditory areas could be identified on the individual anatomy using current estimates from intracerebral data. Such detailed localization approach could also be used prior to epilepsy surgery to help identify epileptogenic foci and preserve functional cortical areas.

Active cochlear micromechanisms, involved in auditory sensitivity, are modulated by the medial olivocochlear efferent system, which projects directly onto the organ of Corti. Both processes can be assessed non-invasively by means of evoked otoacoustic emissions. Animal experiments have revealed top-down control from the auditory cortex to peripheral auditory receptor, supported by anatomical descriptions of descending auditory pathways from auditory areas to the medial olivocochlear efferent system and organ of Corti. Through recording of evoked otoacoustic emissions during presurgical functional brain mapping for refractory epilepsy, we showed that corticofugal modulation of peripheral auditory activity also exists in humans. In 10 epileptic patients, electrical stimulation of the contralateral auditory cortex led to a significant decrease in evoked otoacoustic emission amplitude, whereas no change occurred under stimulation of non-auditory contralateral areas. These findings provide evidence of a cortico-olivocochlear pathway, originating in the auditory cortex and modulating contralateral active cochlear micromechanisms via the medial olivocochlear efferent system, in humans.

Summary: Purpose: Depth electrodes recordings may be required in some cases of epilepsy surgery to delineate the best region for cortical resection. We usually implant depth electrodes according to Talairach’s stereoelectroencephalography (SEEG) method. By using these permanently implanted depth electrodes, we are able to perform radiofrequency (RF)-thermolesions of the epileptic foci. We report the technical data required to perform such multiple cortical thermolesions, as well as preliminary results in terms of seizure outcome in a group of 20 patients. Methods: Lesions were performed by using 100- to 110-mA bipolar current (50 V), applied for 10 to 50 s. Each thermocoagulation produced a 5- to 7-mm diameter cortical lesion. In total, two to 16 lesions were performed in each of the 20 patients. Lesions were placed without anesthesia. No general or neurologic complication occurred during the procedures. Two transient postprocedure side effects, consisting of paresthetic sensations in the mouth and mild apraxia of the hand, were observed. Results: At a follow-up time of 8 to 31 months (mean, 19 months), 15% of the patients became seizure free, 40% experienced a ≥80% reduction of their seizure frequency, and 45% were not significantly improved. Conclusions: SEEG-guided RF thermolesions is a safe technique. Our preliminary results indicate that such lesions can lead to a significant reduction of seizure frequency and could be proposed as a palliative procedure if no resective surgery is possible. A randomized controlled trial is needed to determine which patients are likely to respond to SEEG-guided RF ther

OBJECTIVE The nerve function of Cranial Nerve VIII is at risk during microvascular decompression for hemifacial spasm. Intraoperative monitoring of brainstem auditory evoked potentials (BAEPs) can be a useful tool to decrease the danger of hearing loss. The aim of this study was 1) to assess the side effects of surgery on hearing and describe the main intraoperative BAEP changes observed in the authors' series, and 2) to define warning values beyond which the probability of hearing impairment rises significantly. These values were calculated by correlating the (possible) postoperative hearing disturbances evaluated in terms of pure tone average with intraoperative BAEP changes (especially delay in Wave V latency). METHODS This series included 84 consecutive patients affected with hemifacial spasm who underwent microvascular decompression during which BAEPs were monitored. During surgery, Wave I, I to V interpeak interval, latency, and amplitude of Wave V were recorded and measured. Auditory function was studied before and after surgery and expressed as a pure tone average in all patients. Then, correlations were made between hearing impairment after surgery and intraoperative BAEP changes in an attempt to define warning values. RESULTS Seventy-four patients (88%) had no hearing loss after surgery (Group 1). Eight patients (9.5%) had hearing impairment with a decrease in pure tone average of more than 20 dB (Group 2). Two patients (2.3%) experienced a definitive and complete hearing loss on the side operated on (Group 3). Among intraoperative BAEP changes, latency of Peak V was the most frequently observed and the most significant phenomenon, especially during cerebellar retraction and the decompression step of the microvascular decompression procedure. In the group of patients without hearing loss (Group 1), the mean delay in latency of Peak V was 0.61 millisecond (standard deviation, +/-0.36 ms); in the group with hearing decrease (Group 2), the mean delay was 1.05 milliseconds (standard deviation, +/-0.64 ms); and in the group with deafness (Group 3), Wave V was abolished. CONCLUSION From a practical standpoint, three warning values, based on delay in latency of Peak V, were established for use during surgery: an initial one at 0.4 millisecond ("watching" signal) at the safety limit; a second one at 0.6 millisecond (risk "warning" signal), which is the mean value corresponding to the group of patients without postoperative hearing loss; and an ultimate one at 1 millisecond ("critical" warning), before irreversibility. These warnings should help the surgeon to avoid or correct maneuvers that are dangerous for hearing function, which is mandatory in functional surgery.

Introduction The purpose of this monocentric study was to assess the long-term outcome of a group of severe traumatic brain-injured patients and explore the prognostic values of some clinical and paraclinical parameters available at the initial stage. Methodology The patients included were victims of severe traumatic brain injuries in 2007 or 2008. A standardized assessment was performed for each patient including clinical, radiological, and electrophysiological data collected at the initial stage, The outcomes were assessed at least 2 years after injury. Depending on the patients’ availability and ability to communicate, the assessments included measures of dependency for activities of daily living (ADL), cognitive functions, behaviour, mood, and quality of life. Results Eighteen patients were included, of whom ten were autonomous for ADL at the time of assessment. Memory complaints, attentional deficits, anxiety, and irritability were the main long-term impairments observed. A correlation analysis showed significant correlations between the dependency level (as rated by the Functional Independence Measure) and each of length of coma, length of the post-traumatic amnesia, and the N100 auditory evoked potentials. Discussion These results confirm the uniqueness of each patient regarding the long-term consequences of a traumatic brain injury and the multi-determined nature of each prognosis.

Objective To investigate automatic event-related potentials (ERPs) to an auditory change in migraine patients. Methods Auditory ERPs were recorded in 22 female patients suffering from menstrually-related migraine and in 20 age-matched control subjects, in three sessions: in the middle of the menstrual cycle, before and during menses. In each session, 200 trains of tone-bursts each including two duration deviants were presented in a passive listening condition. Results In all sessions, duration deviance elicited a mismatch negativity (MMN) showing no difference between the two groups. However, migraine patients showed an increased N1 orienting component to all incoming stimuli and a prolonged N2b to deviance. They also presented a different modulation of P3a amplitude along the menstrual cycle, which tended to normalise during migraine attacks. None of the studied ERP components showed a default of habituation. Conclusions This passive paradigm highlighted increased automatic attention orienting to auditory changes but normal auditory sensory processing in migraineurs. Significance Our observations suggest normal auditory processing up to attention triggering but enhanced activation of attention-related frontal networks in migraineurs.

Object of the Study: In some candidates for epilepsy surgery in whom the decision to operate is difficult to make, invasive presurgical investigations, namely depth electrode recordings, may be needed. The SEEG (StereoElectroEncephaloGraphy) method consists of stereotactic orthogonal implantation of depth electrodes (5 to 15, 11 on average). The object of this study is to clarify the indications for SEEG, to expose its complications, and to display its usefulness in terms of surgical strategy and results. Patients and Methods: 100 patients, suffering from drug-resistant epilepsy and selected as candidates for surgical resection, underwent SEEG between 1996 and 2000. A total of 1,118 electrodes were implanted. For each single case, the sites of implantation of the electrodes were chosen in order to determine either the side of the onset of seizures, or the uni- or multilobar feature of them, or a possible operculo-insular propagation from a temporal onset, and also, using direct electrode stimulation, the proximity of speech or motor area. Results: Complications occurred in 5 patients (2 superficial infections, 2 breakages of electrodes, and 1 intracerebral hematoma responsible for death). SEEG was helpful in most (84%) of the 100 patients to confirm or annul surgical indication, and to adjust the extent of the resection. In some cases (14%), SEEG allowed to propose a resection that might have been disputable based solely on noninvasive investigation data. For frontal epilepsy, SEEG was crucial in all cases to delineate the extent of resection. Conclusion: SEEG proved to be a relatively safe and a very useful method in ‘difficult’ candidates for epilepsy surgery. In addition, in some cases the implanted electrodes can be used to perform therapeutic RF thermocoagulation of epileptic foci or networks.

Background This study compared the administration of 0.1% ropivacaine and 0.5 microg/ml sufentanil with that of 0.1% bupivacaine and 0.5 microg/ml sufentanil via patient-controlled epidural analgesia route during labor. Methods Two hundred healthy pregnant women at term with a single fetus with a vertex fetal presentation were randomized in a double-blind fashion to receive either 0.1% ropivacaine and 0.5 microg/ml sufentanil or 0.1% bupivacaine and 0.5 microg/ml sufentanil using a patient-controlled epidural analgesia pump (5-ml bolus dose, 10-min locked-out period, no basal infusion). Pain score on a visual analog scale, Bromage score (0-3), level of sensory block, patient-controlled epidural analgesia ratio, drug use, supplemental boluses, and side effects were recorded at 30 min and then hourly. Mode of delivery, duration of first and second stages of labor, umbilical cord pH, Apgar scores of the newborn, and a measure of maternal satisfaction were recorded after delivery. Results No differences were seen between the two groups for pain scores on a visual analog scale during labor, volume of anesthetic solution used, mode of delivery, or side effects. Motor block during the first stage of labor was significantly less in the ropivacaine group than in the bupivacaine group (no motor block in 97.8 of patients vs. 88.3%, respectively; P < 0.01). Duration of the second stage of labor was shorter in the ropivacaine group (1.3 +/- 1.0 vs. 1.5 +/- 1.2 h [mean +/- SD]; P < 0.05). Maternal satisfaction was greater in the bupivacaine group (91 +/- 13 mm for contraction, 89 +/- 19 mm for delivery on a visual scale: 0 = not satisfied at all, 100 = fully satisfied) than in the ropivacaine group (84 +/- 21 and 80 +/- 25 mm; P < 0.0001). Patients in the ropivacaine group requested more supplemental boluses to achieve analgesia during the second stage of labor than those in the bupivacaine group (29.7 vs. 19.8%, respectively, requested one or more supplemental boluses; P < 0.05). Conclusions Delivered as patient-controlled epidural analgesia, 0.1% ropivacaine and 0.5 microg/ml sufentanil produce less motor block but are clinically less potent than 0.1% bupivacaine and 0.5 microg/ml sufentanil.

Continuous long-term recording of brainstem (BAEPs), middle-latency (MLAEPs) and long-latency auditory evoked potentials, including the mismatch negativity (MMN), brings additional information on the immediate functional state and the outcome of patients in coma or recovering after surgery, in relation with clinical observations and therapeutics. A recently designed monitoring system is introduced, aimed at the continuous recording of late auditory potentials (N100 and MMN) as well as BAEPs and MLAEPs. Specific methodological aspects are emphasized. Long-term monitoring data from one patient recorded in the recovery room after surgery are displayed, allowing an illustration of the techniques used and of the problems raised.

Objectives : The purpose of this study was to assess the patterns of mismatch negativity (MMN) and N100 component in comatose patients and to evaluate their prognostic value vis-a-vis return of consciousness. Methods : MMN and auditory (early, middle-latency and late) evoked potentials were recorded in 52 normals and in 128 comatose patients (comas due to neurosurgical and neurological problems). At the time of recording, all patients scored lower than 8 on the Glasgow scale. Results : Visually detected N100 and MMN were confirmed by cross-correlation of sub-averages. The MMN was present in 33/128 patients and the N100 component in 84/128. The amplitudes of MMN and N100 waves detected in comatose patients were statistically different from those of normal subjects. By 3 months after the onset of coma, 95 patients had returned to consciousness, most of them with moderate to severe disability. A ratio of 30/33 patients with MMN and 70/84 with N100 had regained consciousness. The presence of a MMN together with a N100 component was more specific (90.9%) than the presence of a N100 component irrespective of MMN (57.6%) in terms of predicting return to consciousness, but its sensitivity was lower (respectively 31.6% for MMN and 73.7% for N100). The mean period that elapsed between the recording of evoked potentials and a return to consciousness was 6.3±4 days. MLAEPs were also highly specific, but BAEPs were not. Conclusion : MMN and auditory evoked potentials provide a reliable assessment of the functional status of comatose patients. When present, MMN and the N100 differ from those found in normal subjects in terms of latencies and amplitudes. As a predictor of return of consciousness MMN had high specificity and low sensitivity, whereas the N100 had high sensitivity and low specificity. This study demonstrates that the recording of MMN and the auditory N100 can be a very useful aid in the assessment of coma and in predicting whether or not a patient will regain consciousness.

{#article-title-2} I read with interest the report of Teo et al.1 on acute vascular syndromes attributed to cerebral microbleeds (CMBs). Assessing neurologic presentations in these patients can be challenging; we recently encountered a patient who illustrated the diversity of presentation of this condition. A 53-year-old man with previous whole brain irradiation for metastatic cancer reported repeated episodes of slowly progressive (over 5–60 minutes) unilateral weakness, proceeding to right or left hemiplegia lasting several hours. There was a visual disturbance at symptom onset and a unilateral headache at some stage. Neurologic examination and routine EEG were normal; brain MRI demonstrated multiple widespread punctuate CMBs (figure). Complex secondary migraine was diagnosed and prophylactic treatment suggested. Months later the patient presented to his local hospital with a further such episode progressing to complete flaccid right hemiplegia and global aphasia. Neuroimaging showed no new changes. He was transferred to our center after a week of failing to improve. Though … Correspondence to: jthteo{at}gmail.com Correspondence to: sethinitinmd{at}hotmail.com Correspondence to: jacques.luaute{at}chu-lyon.fr

Resume Nous avons realise l'exploration fonctionnelle de la voie auditive chez 67 patients atteints d'accidents vasculaires cerebraux ischemiques ou hemorragiques du territoire vertebrobasilaire, en effectuant des potentiels auditifs precoces (PEAP) et de latence moyenne (PEALM) (chez 39 d'entre eux), en complement de l'imagerie morphologique (IRM ou TDM). Les PEAP sont anormaux chez 41 des 67 patients, et les PEALM sont anormaux chez 25 des 39 patients en ayant beneficie. Les anomalies electrophysiologiques predominent lors de lesions massives du tronc cerebral (atteintes pontomesencephaliques ou bulbopontiques), ainsi que dans les lesions localisees a la protuberance. Elles sont homolaterales a la lesion anatomique hormis deux cas. Tous les patients ayant des PEAP normaux ont une conscience normale. La normalite des PEALM chez les patients comateux apparait comme un facteur de bon pronostic. L'etude des modifications des reponses auditives precoces et de latence moyenne s'avere complementaire de l'examen clinique et des donnees de l'imagerie, en temps qu'aide a la localisation lesionnelle et determination d'un facteur pronostic.

Resume Les auteurs ont fait une revue de l'effet des anesthesiques sur les potentiels evoques (PE) auditifs precoces et de latence moyenne, sur les potentiels somesthesiques et sur les potentiels visuels. Les effets des anesthesiques intraveineux et des anesthesiques volatiles ont ete successivement etudies. La surveillance neurophysiologique sous anesthesie generale sera d'autant plus efficace qu'elle prendra en compte les notions suivantes : 1) les anesthesiques volatiles halogenes exercent une action plus puissante sur les PE que les anesthesiques intraveineux, ceci quelle que soit la modalite sensorielle consideree ; 2) les reponses corticales sont plus sensibles a l'action des anesthesiques que les reponses sous-corticales ; 3) la reponse corticale primaire est plus resistante que les composantes plus tardives ; 4) l'administration continue des anesthesiques doit etre preferee a l'administration discontinue en bolus. Les PE peuvent egalement etre utilises en tant que mesure de la profondeur anesthesique ; pour cela, les reponses auditives de latence moyenne semblent actuellement les mieux adaptees. Enfin certains problemes poses par l'administration des anesthesiques intraveineux en reanimation ont ete abordes.

Objective To investigate long-term (LTH) and short-term (STH) habituation of auditory event-related potentials (ERPs) during a migraine cycle, using a classic habituation paradigm. Methods In 22 patients suffering from menstrually-related migraine and in 20 age-matched control subjects, auditory ERPs were recorded in 3 sessions: in the middle of the menstrual cycle, before menses, and during menses. In 12 patients, a migraine attack occurred during one of the peri-menses sessions. In each session, 200 trains of stimuli were presented, with an average of 10 stimuli per train. Results In response to the first stimuli of the trains, migraineurs exhibited in all sessions a larger orienting component of N1 than matched controls and a larger P3a in the interictal session, which normalized during attacks. They also showed a residual orienting component in response to the subsequent stimuli inside the trains. In contrast, the sensory component of N1 showed no difference between the two groups, with similar STH and LTH. Conclusions Migraineurs show an exacerbated attention orienting to auditory stimulation, without any habituation deficit. Significance Previous migraine studies reported interictal habituation deficits of ERPs, but demonstrated in the auditory modality only in paradigms testing intensity dependence. Previous and current results can be interpreted as an increased attention orienting, possibly relying on an abnormal involvement of frontal cortex in auditory processing.

The authors have reviewed hearing results obtained in 99 patients operated on via the suboccipital approach for acoustic neurinoma, who were not deaf prior to surgery (pure tone average less than 70 dB). Tumor size was less than 10 mm in four cases, 10 to 19 mm in 26 cases, 20 to 29 mm in 39 cases, and 30 mm or greater in 30 cases. Removal was macroscopically complete in 92 cases and incomplete in seven, including four cases with bilateral acoustic neurofibromatosis. Hearing was preserved in 29 patients (29.3%), of whom 23 had neurinomas smaller than 30 mm and six had tumors exceeding 30 mm in size. Postoperative hearing was good in eight cases (four with neurinomas less than 20 mm and four with neurinomas greater than 20 mm), serviceable in four cases (three with neurinomas less than 20 mm and one with a tumor greater than 30 mm), and poor in 17 cases (eight with neurinomas less than 20 mm and nine with tumors greater than 20 mm). Fifty-seven patients underwent intraoperative brain-stem auditory evoked potential monitoring: the rate of hearing preservation was found to be higher in this group than in the 42 without monitoring (p less than 0.05). A statistical study using stepwise regression analysis showed that the two preoperative factors most significantly associated with postoperative hearing preservation are a good auditory level for low frequencies measured by pure tone audiometry and a small-sized tumor. Overall results indicate that, even if hearing is more easily preserved when the neurinoma is small and the preoperative auditory condition is good, the surgeon should try to save hearing in all patients who have preserved hearing before surgery.

Objective To assess patterns of novelty P3 elicited by the subject’s own name (SON) in comatose patients and to compare SON novelty P3 prognostic value with that of mismatch negativity (MMN). Methods A passive oddball paradigm, previously validated in healthy subjects, including duration deviants and SON presented as a novel was applied in 50 severe comatose patients on average 20 days after coma onset. The outcome was assessed 3 months after coma onset. Results MMN to deviants was found in 14/50 patients and a central–parietal P3 to SON was found in 21/50 patients. In 12 patients, a parietal component (P3b) was also clearly present in the late part of P3. Four patients showed an MMN but no P3. Eleven patients had a novelty P3, with a late parietal component for 5 of them, but no MMN. The presence of a P3 was highly correlated with awakening. Compared to MMN, P3 showed as large a specificity for awakening (0.85). It showed a much higher sensitivity (0.71 versus 0.42). All but one patient with P3b woke up. Conclusions The use of novelty P3 elicited by SON increases the prognostic value of MMN alone and improves the assessment of comatose patients by demonstrating the activation of higher-level cognitive functions in some of them. It shows that unconsciously perceived stimuli are processed and activate brain areas similarly to consciously perceived stimuli. Significance SON as a novel in an MMN design can be used to increase the prognostic value of ERPs in comatose patients and to assess unconscious cognitive processes in uncommunicative patients.

International audience; Hemodynamic studies have shown that the auditory cortex can be activated by visual lip movements and is a site of interactions between auditory and visual speech processing. However, they provide no information about the chronology and mechanisms of these cross-modal processes. We recorded intracranial event-related potentials to auditory, visual, and bimodal speech syllables from depth electrodes implanted in the temporal lobe of 10 epileptic patients (altogether 932 contacts). We found that lip movements activate secondary auditory areas, very shortly (approximately equal to 10 ms) after the activation of the visual motion area MT/V5. After this putatively feedforward visual activation of the auditory cortex, audiovisual interactions took place in the secondary auditory cortex, from 30 ms after sound onset and before any activity in the polymodal areas. Audiovisual interactions in the auditory cortex, as estimated in a linear model, consisted both of a total suppression of the visual response to lipreading and a decrease of the auditory responses to the speech sound in the bimodal condition compared with unimodal conditions. These findings demonstrate that audiovisual speech integration does not respect the classical hierarchy from sensory-specific to associative cortical areas, but rather engages multiple cross-modal mechanisms at the first stages of nonprimary auditory cortex activation.

In noisy environments, we use auditory selective attention to actively ignore distracting sounds and select relevant information, as during a cocktail party to follow one particular conversation. The present electrophysiological study aims at deciphering the spatiotemporal organization of the effect of selective attention on the representation of concurrent sounds in the human auditory cortex. Sound onset asynchrony was manipulated to induce the segregation of two concurrent auditory streams. Each stream consisted of amplitude modulated tones at different carrier and modulation frequencies. Electrophysiological recordings were performed in epileptic patients with pharmacologically resistant partial epilepsy, implanted with depth electrodes in the temporal cortex. Patients were presented with the stimuli while they either performed an auditory distracting task or actively selected one of the two concurrent streams. Selective attention was found to affect steady-state responses in the primary auditory cortex, and transient and sustained evoked responses in secondary auditory areas. The results provide new insights on the neural mechanisms of auditory selective attention: stream selection during sound rivalry would be facilitated not only by enhancing the neural representation of relevant sounds, but also by reducing the representation of irrelevant information in the auditory cortex. Finally, they suggest a specialization of the left hemisphere in the attentional selection of fine-grained acoustic information.

With a view to elaborating a clinical tool to assess cognitive functions in brain-damaged patients, we had previously displayed characteristic patterns of ERPs (32 electrodes) in awake healthy persons in response to their own name (SON) presented as a novel in a passive oddball paradigm. In the present combined ERP and PET study, in an attempt to identify brain correlates of duration MMN and response to SON uttered by a familiar (FV) or an unknown voice (NFV), we used a block design protocol as close as possible to the aforementioned SON protocol. ERP data showed robust duration MMN and novelty P3 in response to SON similar to our previous results. The PET technique did not allow true MMN generators to be disclosed, but blocks with duration deviants elicited an increase of activation in the right temporal pole as compared with the control condition with no deviants, supporting the hypothesis of right hemispheric dominance in early sound discrimination. For SON contrasts, robust cerebral blood flow activation present over temporal, frontal and parietal cortices, in the hippocampus and in the precuneus could be associated with speech, novelty and self-recognition processing. Familiar and unfamiliar voices activated the prefrontal cortex differently, suggesting different retrieval processes, although corresponding ERP responses could not be differentiated.

Luaute J, Fischer C, Adeleine P, Morlet D, Tell L, Boisson D. Late auditory and event-related potentials can be useful to predict good functional outcome after coma. Objective To investigate whether late auditory and event-related potentials, and in particular N100 and mismatch negativity, together with clinical parameters, can help to predict good functional outcome in comatose patients. Design Prospective cohort study. Setting Hospital. Participants Consecutively sampled comatose patients (N=346) whose etiologies of coma were stroke (125 patients), brain injury (96 patients), anoxia (64 patients), complication of neurosurgery (54 patients), and encephalitis (7 patients). Interventions Not applicable. Main outcome measures Glasgow Outcome Scale score at 1 year postonset. Patients in a minimally conscious state and those who awoke and died during the follow-up period were classified separately. Results Univariate analysis showed that all variables studied, except brainstem auditory evoked potentials, correlated significantly with functional outcome. Mismatch negativity showed the highest positive predictive value for good outcome. A validated model was obtained with multivariate logistic analysis, including pupillary light reflex, N100, mismatch negativity, etiology, and age. Conclusions Late auditory and event-related potentials, and particularly N100 and mismatch negativity, provide strong prognostic factors for good functional outcome. Furthermore, these components may enhance the accuracy of prognosis when associated with other clinical parameters available at the early stage of coma.

Auditory disorders resulting from focal brainstem lesions are rarely symptomatic. Isolated lesions of the inferior colliculus have previously been reported, whereas no detailed description of a localized involvement of the lateral lemniscus is yet available. We report a unilateral lesion of the lateral lemniscus by a bleeding in a cavernoma. Symptoms included strictly contralateral tinnitus and auditory impairment, with normal pure-tone and speech audiometry. Conversely, the dichotic listening test revealed an extinction of contralateral ear input. The brainstem auditory evoked potentials disclosed a reduced and delayed wave V only after contralateral ear stimulation, while the middle latency evoked potentials were normal. This observation shows that a unilateral lesion of the lateral lemniscus can produce auditory symptoms. The dysfunction of auditory pathways is associated with specific electrophysiological abnormalities that can be assessed by evoked potential recording.

Publisher Summary This chapter presents a prospective study of 346 comatose patients, to study and confirm the known interest of short-latency evoked potentials (EPs), to determine if late (N 100) and cognitive mismatch negativity (MMN) auditory evoked potentials (AEP) have an awakening prognostic value better than the short-latency EPs alone. The patients belonging to the categories of recovery, moderate disability, severe disability, minimally responsive state, or unrelated death are classified as awakening. Patients in a vegetative state, persistent coma, or death categories are classified as no awakening. This study, based on a large prospective series, shows the interest to record late AEPs and cognitive EPs in the awakening prognostic. Ten patients with MMN failed to regain consciousness. In this study, 80.3% of the comatose patients in whom the N100 component was present finally awoke. The study confirms the interest of the short-latency evoked potentials in the functional evaluation of comatose patients.

Objective To describe sonographic findings in livers of pregnant women with severe preeclampsia and abdominal pain. Methods Over a 12-month period, we performed serial sonographic examinations on 32 pregnant women with severe preeclampsia and acute right upper quadrant and epigastric pain. On each sonogram we observed the liver size and texture, "periportal halo" sign, gallbladder wall, Glisson capsule thickness, painful compression of the liver and gallbladder, and ascites. The pancreas, spleen, kidneys, and uterus were also studied. Sonography was repeated after delivery. Results Initial sonograms showed liver abnormalities in 28 patients. Abnormalities consisted of liver hypertrophy (n = 24), hyperechoic thickening of the periportal area (periportal halo sign; n = 23), striated thickening of the gallbladder wall (n = 27), hyperechoic thickening of the Glisson capsule (n = 11), liver areas of increased echogenicity (n = 11), subcapsular hematoma (n = 1), and subcapsular calcification (n = 1). Probe compression of the liver enhanced abdominal pain (n = 13), whereas the gallbladder was painless in all cases. No gallbladder stones were detected. Ascites (n = 16) and pleural effusion (n = 11) were also present. In no case did we detect abnormalities of the pancreas, kidneys, or spleen. All patients eventually had hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome according to the American College of Obstetricians and Gynecologists classification. In 7 cases, HELLP syndrome developed postpartum. Three patients also had eclampsia. Follow-up sonograms highlighted quick regression of abnormalities after delivery. Conclusions The livers of women with severe preeclampsia who had HELLP syndrome showed sonographic abnormalities before biological abnormalities. Serial sonographic examinations could therefore contribute to the obstetric care of these women. Preeclampsia and HELLP syndrome should be routinely checked for in all pregnant women with acute abdominal pain.

Publisher Summary Coma is a state of apparently absent or suspended consciousness, complicating various clinical conditions, for example, circulatory arrest or head trauma. In recent times, interest is growing in the assessment of coma and in predictors of awakening and recovery. With respect to auditory evoked potentials short-latency responses (BAEPs) that explore the brainstem and middle-latency responses (MLAEPs), exploring the primary auditory cortex, have been used more often than late auditory evoked responses. It is only recently that event-related potentials (ERPs) have been studied in comatose patients. The use of P300 in comatose patients is questionable, as it is closely related to attention and decision-making. Recording mismatch negativity (MMN), in comatose patients, is more suitable, as it can be elicited in the absence of attention— that is, when no task performance is required —and it is best recorded in conscious subjects, using a passive condition in which attention is directed away from the auditory stimulation. The MMN is mainly generated by the auditory cortex. It depends on the presence of a memory trace formed by the preceding standard stimulus. The chapter describes and discusses the procedure and the result, respectively, of a few studies in detail that have dealt with MMN recording results in comatose patients.

Mismatch negativity (MMN) and N100 auditory evoked potential were recorded in 52 healthy subjects and in 128 severely comatose patients. The MMN was present in 33/128 patients and N100 in 84/128. A ratio of 30/33 patients with MMN and 70/84 with N100 regained consciousness in a mean time of 6.3 ± 4 days after the recording session. Thus, in terms of predicting return to consciousness, the MMN was more specific (90.9%) than the N100 (57.6%), but its sensitivity was lower (31.6% for MMN and 73.7% for N100, respectively). The amplitudes of MMN and N100 in comatose patients were smaller than those of healthy subjects. It is concluded that MMN and N100 can be very useful in predicting whether or not a comatose patient will regain consciousness.

Objective: The aim of this study was to determine the course of the temporal optic radiations. Material and Methods: Eighteen patients were included in this prospective study. All of them underwent a temporal lobectomy for epilepsy, including the mesial temporal structures and a variable extent of lateral neocortex (from 2 to 7 cm behind the temporal tip). An MRI was performed 2 months postoperatively, allowing assessment of the extent of lateral resection. Postoperative visual fields were determined by automatic static perimetry (ASP). Results: (1) No patient complained of a disabling visual field deficit. (2) ASP, a highly sensitive technique, however, detected postoperative visual field deficits in 83% of patients, confined to the superior homonymous field contralateral to the resection. (3) A strong correlation was found between the presence of a visual field deficit and the extent of laterotemporal resection. (4) The smallest anteroposterior resection resulting in a field defect was limited to 20 mm from the temporal tip. Conclusion: (1) This study confirms a strong correlation between postoperative visual field deficits and the extent of lateral neocortical temporal resection. (2) The anterior limit of Meyer’s loop is likely to be located more rostrally than previously believed. (3) Despite this, lateral resection remains useful in some cases for seizure control.