Name: pupillary response as assessment of effective seizure induction by electroconvulsive therapy
Uploaded: 2019-04-11T14:00:00
Description: Watch this Scientific Journal Video about Pupillary Response as Assessment of Effective Seizure Induction by Electroconvulsive Therapy at JoVE.com

The study protocol was approved by the institutional clinical research ethics committee of Kyushu University, Fukuoka, Japan (IRB: Clinical Research number #28-77). Although the measurement of pupillary reaction is an essential and standard clinical procedure during anesthesia, informed consent was obtained for this research. Patients with cataract, glaucoma, intraocular lenses, or insulin-dependent diabetes mellitus were excluded because their pupillary responses may be abnormal.
1. Preparation...

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Automated infrared pupillometer devices have been used to measure pupillary reactions in clinical situation12. However, to our knowledge, no previous studies have used this equipment for detecting the efficacy of seizure induction by ECT. Resting pupil diameter size differs between patients, but constriction ratio provides an objective measure. Thus, we selected the constriction ratio change, not the diameter size change. Additionally, small changes of pupillary diameter can only be measured using...

Electroconvulsive therapy (ECT) is considered an effective treatment for severe neuropsychiatric disorders, including refractory psychosis, bipolar disorder, and depression1. In ECT, an electrical current is applied to the brain to induce a seizure under general anesthesia2. Although the mechanisms underlying ECT remain unclear, its antidepressant effects have been attributed to seizure-induced changes in neurotransmitter levels, improved neuroplasticity, increased functional connectivity, and an increase in the plasmatic production of brain-derived neurotrophic factor3. It has also been reported that ECT facilitates serotonin-, norepinephrine- and dopamine-mediated neurotransmission4. These findings suggest that ECT could cause activation of the sympathetic nervous system. Previous studies have evaluated adequate seizure induction by ECT using seizure duration, symmetrical seizure amplitude, postictal suppression, and activation of the sympathetic nervous system4,5. Among these factors, increased activation of the sympathetic nervous system cannot be measured using electroencephalography. Detection of sympathetic nervous system activation is dependent on increased blood pressure (BP) and heart rate (HR). However, these hemodynamic parameters do not always reflect sympathetic responses because of the administration of antihypertensive drugs to prevent cardiac events during ECT and anesthetic agents, which affect sympathetic nervous function.
Pupillary responses can reflect the degree of brain damage6. Thus, pupillary mydriasis is indicated for severe brain damage6. Artificial seizures induced by electrical stimulation constitute an abnormal state of brain activity. Thus, evaluating the pupillary response immediately after ECT may be useful for assessing the efficacy of ECT because ECT may also influence pupillary responses7. However, measuring pupillary responses in busy clinical situations, as in the current case, is often difficult. To address this issue, a measurement method using an infrared quantitative pupillometer could help to measure pupillary responses easily, accurately, objectively and reproducibly. Quantitative pupillary assessment methods are superior to those obtained manually at the bedside, even by experienced nurses and physicians8. The proposed method for measuring pupillary reactivity using an automated infrared pupillometer could be useful for detecting the degree of seizure or sympathetic nervous activation. In a previous study, we reported that the pupillary light reflex was related to the efficacy of seizure by ECT9. Specifically, we found that pupillary diameter was not changed after light stimulation, remaining enlarged when adequate seizure was induced. Thus, the aim of the proposed method is to measure the light reflex using an automated infrared pupillometer immediately after electrical stimulation. The proposed method is easy to perform, enabling any clinician, not only psychiatrists, to evaluate the efficacy of seizure induction using ECT.

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pupillary response as assessment of effective seizure induction by electroconvulsive therapy

Electroconvulsive therapy (ECT) is reported to be effective for severe neuropsychiatric disorders. In ECT, electrical stimulation is applied to the brain, inducing seizure activity. Adequate seizure induction with ECT is associated with seizure duration, symmetrical high amplitude waveforms during slow-wave activity, postictal suppression, and activation of the sympathetic nervous system. Sympathetic nervous system activation is influenced by anesthetic agents or cardiovascular drugs during ECT. Pupillary responses can reflect sympathetic nervous activity or the degree of brain damage. Pupillary response measurement can be conducted in a simple, precise, and objective way using an automated infrared pupillometer, enabling the measurement of pupil diameter (mm) to two decimal places. The white light used for measuring light reflexes is not overly bright, and patients do not typically report discomfort. Pupillary light reflexes were measured before anesthesia induction and immediately after electrical stimulation using this equipment. Pupil diameter is typically enlarged after brain damage or sympathetic nervous activation. Adequate seizure induction using ECT could induce pupillary enlargement immediately after electrical stimulation. In the current method, the constriction ratio of pupil size was calculated automatically and compared with seizure quality. Pupillary responses immediately after electrical stimulation may provide a useful assessment of the efficacy of seizure induction with ECT.

Portable pupillometer devices are produced by several companies. These devices are typically conveniently sized and can be operated with one hand (Figure 1A), enabling examiners to accurately detect pupillary responses by pressing a button. Infrared light is used to detect the pupillary edge automatically (Figure 1B), accurately representing pupillary data (Figure 1C). This device m...

Watch this Scientific Journal Video about Pupillary Response as Assessment of Effective Seizure Induction by Electroconvulsive Therapy at JoVE.com

Pupillary Response as Assessment of Effective Seizure Induction by Electroconvulsive Therapy

Pupillary responses (light reflex) were measured for assessment of adequate seizure induction by electroconvulsive therapy using an automated infrared pupillometer immediately after electrical stimulation. Constriction ratio was calculated and compared with seizure quality.

Electroconvulsive therapy (ECT) is reported to be effective for severe neuropsychiatric disorders. In ECT, electrical stimulation is applied to the brain, ...

The efficacy of ECT, electroconvulsive therapy, has been evaluated based on electroencephalography and increases in BP or HR, however, an increasing number of patient have adapted to ECT and rates of cardiovascular disease are increasing. On the other hand, pupillary responses can reflect sympathetic nervous activity or the degree of brain damage. This proposed method might be particularly useful for patients who have been administered anti-hypertensive drugs during ECT.Pupillary response measurement using an automated infrared pupillometer can be conducted in a simple, precise, and objective way and not be affected by anesthetic agents or anti-hypertensive drugs. Additionally, the white light used for measuring light reflexes is not overly bright and harmful for patients. Begin by cleaning the right and left forehead and the area behind the ears with an alcohol cotton swab.Next, attach electroencephalogram or EEG monitors at four symmetrical points. Clean bilateral temples with normal saline and then attach adhesive electrical stimulation pads to the bilateral temples to prevent interference in the stimulation due to hair. Then, attach the electrocardiogram or ECG monitors at the base of the heart and cardiac apex and monitor heart rate.Next, prepare a tourniquet and belt it at the left thigh. Lastly, attach two electromyogram sensors to the left anterior tibial muscle with a distance of five centimeters to measure generalized seizure time in the lower leg. After anesthetizing the patient, begin the electroconvulsive therapy or ECT procedure by using an ECT instrument set at an initial electrical stimulus dose percentage at half the value of the patient's age.Then, immediately after electrical stimulation, hold the automated infrared pupillometer over one of the patient's eyes. After the patient's eyes are opened by an examiner, press the device button and measure maximum resting pupil size or minimum pupil size after stimulation. Next, perform controlled ventilation using a face mask with 100%oxygen until the patient begins breathing spontaneously.Finally, using EEG, measure ictal regularity, seizure time, and greater post-ictal suppression. Results indicate that pupillary diameter was increased after electrical stimulation, however, significant differences in constriction by the light reflex were caused immediately after electrical stimulation reflecting differences in seizure efficacy induced by ECT. For this study, automated infrared pupillometer is essential.Measurements should be conducted immediately after electrical stimulation because pupillary reactions recover rapidly. For adequate seizure evaluation, pupillary reaction might be included in the future. Pupillary reaction might be one of the evaluations for degree of epilepsy or non-induced seizure.Hemodynamics are dynamically changed immediately after electrical stimulation, therefore, the anesthesiologist should not excessively focus on evaluating pupillary response but ensure there is consistent monitoring of the patient's vital signs.

pupillary-response-as-assessment-effective-seizure-induction

Research

JoVE Journal

Behavior

Quantifying Learning in Young Infants: Tracking Leg Actions During a Discovery-learning Task

Task-specific actions emerge from spontaneous movement during infancy. It has been proposed that task-specific actions emerge through a discovery-learning process. Here a method is described in which 3-4 month old infants learn a task by discovery and their leg movements are captured to quantify the learning process. This discovery-learning task uses an infant activated mobile that rotates and plays music based on specified leg action of infants. Supine infants activate the mobile by moving their feet vertically across a virtual threshold. This paradigm is unique in that as infants independently discover that their leg actions activate the mobile, the infants&#8217; leg movements are tracked using a motion capture system allowing for the quantification of the learning process. Specifically, learning is quantified in terms of the duration of mobile activation, the position variance of the end effectors (feet) that activate the mobile, changes in hip-knee coordination patterns, and changes in hip and knee muscle torque. This information describes infant exploration and exploitation at the interplay of person and environmental constraints that support task-specific action. Subsequent research using this method can investigate how specific impairments of different populations of infants at risk for movement disorders influence the discovery-learning process for task-specific action.

A method is described in which 3-4 month old infants learn a task by discovery and their leg movements are captured to quantify the learning process.

Task-specific actions emerge from spontaneous movement during infancy. It has been proposed that task-specific actions emerge through a discovery-learning ...

A Protocol of Manual Tests to Measure Sensation and Pain in Humans

Numerous qualitative and quantitative techniques can be used to test sensory nerves and pain in both research and clinical settings. The current study demonstrates a quantitative sensory testing protocol using techniques to measure tactile sensation and pain threshold for pressure and heat using portable and easily accessed equipment. These techniques and equipment are ideal for new laboratories and clinics where cost is a concern or a limiting factor. We demonstrate measurement techniques for the following: cutaneous mechanical sensitivity on the arms and legs (von-Frey filaments), radiant and contact heat sensitivity (with both threshold and qualitative assessments using the Visual Analog Scale (VAS)), and mechanical pressure sensitivity (algometer, with both threshold and the VAS). The techniques and equipment described and demonstrated here can be easily purchased, stored, and transported by most clinics and research laboratories around the world. A limitation of this approach is a lack of automation or computer control. Thus, these processes can be more labor intensive in terms of personnel training and data recording than the more sophisticated equipment. We provide a set of reliability data for the demonstrated techniques. From our description, a new laboratory should be able to set up and run these tests and to develop their own internal reliability data.

The goal of this procedure is to demonstrate a battery of quantitative techniques for sensory and pain measurement in humans. The equipment and techniques described are commonly found in pain clinics or are easy to obtain.

Numerous qualitative and quantitative techniques can be used to test sensory nerves and pain in both research and clinical settings. The current study ...

An Objective and Child-friendly Assessment of Arm Function by Using a 3-D Sensor

Progressive and irreversible muscle atrophy characterizes Spinal Muscular Atrophy (SMA) and other similar muscle disorder diseases. Objective assessment of muscle functions is an essential and important, although challenging, prerequisite for successful clinical trials. Current clinical rating scales restrain the movement abnormalities to certain predefined coarse-grained individual items. The Kinect 3-D sensor has emerged as a low-cost and portable motion sensing technology used to capture and track people&#39;s movement in many medical and research fields. A novel approach using this 3-D sensor was developed and a game-like test was designed to objectively measure the upper limb function of patients with SMA. The prototype test targeted joint movement capability. While sitting in a virtual scene, the patient was instructed to extend, flex, and lift the whole arm in order to reach and place some objects. Both kinematic and spatiotemporal characteristics of upper limb movement were extracted and analyzed, e.g., elbow extension and flexion angles, hand velocity, and acceleration. The first study included a small cohort of 18 ambulant SMA patients and 19 age- and gender-matched healthy controls. A comprehensive analysis of arm movement was achieved; however, no significant difference between the groups were found due to the mismatch of patient&#39;s capability and the test difficulty. Based on this experience, a second version of the test consisting of a modified version of the first game with increased difficulties and a second game targeting muscle endurance were designed and implemented. The new test has not been conducted in any patient groups yet. Our work has demonstrated the potential capability of the 3-D sensor in assessing such muscle function and suggested an objective approach to complement the clinical rating scales.

An objective measure of muscle functions is challenging especially in children. Based on a commercially available digital 3-D sensor, a child-friendly gaming test was developed to assess upper limb function for clinical trials.

Progressive and irreversible muscle atrophy characterizes Spinal Muscular Atrophy (SMA) and other similar muscle disorder diseases. Objective assessment ...

Computerized Adaptive Testing System of Functional Assessment of Stroke

The computerized adaptive testing system of the functional assessment of stroke (CAT-FAS) can simultaneously assess four functions (motor functions of the upper and lower extremities, postural control, and basic activities of daily living) with sufficient reliability and administrative efficiency. CAT, a modern measurement method, aims to provide a reliable estimate of the examinee's level of function rapidly. CAT administers only a few items whose item difficulties match an examinee's level of function and, thus, the administered items of CAT can provide sufficient information to reliably estimate the examinee's level of function in a short time. The CAT-FAS was developed through four steps: (1) determining the item bank, (2) determining the stopping rules, (3) validating the CAT-FAS, and (4) establishing a platform of online administration. The results of this study indicate that the CAT-FAS has sufficient administrative efficiency (average number of items = 8.5) and reliability (group-level Rasch reliability: 0.88 - 0.93; individual-level Rasch reliability: &#8805;70% of patients had Rasch reliability score &#8805;0.90) to simultaneously assess four functions in patients with stroke. In addition, because the CAT-FAS is a computer-based test, the CAT-FAS has three additional advantages: the automatic calculation of scores, the immediate storage of data, and the easy exporting of data. These advantages of the CAT-FAS will be beneficial to data management for clinicians and researchers.

Here, we present a protocol to develop the computerized adaptive testing system of the functional assessment of stroke (CAT-FAS). The CAT-FAS can simultaneously assess four functions (two motor functions [upper and lower extremities], postural control, and basic activities of daily living) with sufficient reliability and administrative efficiency.

The computerized adaptive testing system of the functional assessment of stroke (CAT-FAS) can simultaneously assess four functions (motor functions of the ...

Multi-Modal Signals for Analyzing Pain Responses to Thermal and Electrical Stimuli

The assessment of pain relies mostly on methods that require a person to communicate. However, for people with cognitive and verbal impairments, existing methods are not sufficient as they lack reliability and validity. To approach this problem, recent research focuses on an objective pain assessment facilitated by parameters of responses derived from physiology, and video and audio signals. To develop reliable automated pain recognition systems, efforts have been made in creating multimodal databases in order to analyze pain and detect valid pain patterns. While the results are promising, they only focus on discriminating pain or pain intensities versus no pain. In order to advance this, research should also consider the quality and duration of pain as they provide additional valuable information for more advanced pain management. To complement existing databases and the analysis of pain regarding quality and length, this paper proposes a psychophysiological experiment to elicit, measure, and collect valid pain reactions. Participants are subjected to painful stimuli that differ in intensity (low, medium, and high), duration (5 s / 1 min), and modality (heat / electric pain) while audio, video (e.g., facial expressions, body gestures, facial skin temperature), and physiological signals (e.g., electrocardiogram [ECG], skin conductance level [SCL], facial electromyography [EMG], and EMG of M. trapezius) are being recorded. The study consists of a calibration phase to determine a subject&#8217;s individual pain range (from low to intolerable pain) and a stimulation phase in which pain stimuli, depending on the calibrated range, are applied. The obtained data may allow refining, improving, and evaluating automated recognition systems in terms of an objective pain assessment. For further development of such systems and to investigate pain reactions in more detail, additional pain modalities such as pressure, chemical, or cold pain should be included in future studies. Recorded data of this study will be released as the &#8220;X-ITE Pain Database&#8221;.

This article focuses on the experimental elicitation of pain through heat (thermal) and electrical stimulation while recording physiological, visual, and paralinguistic responses. It aims at collecting valid multimodal data for analyzing pain based on its intensity, quality, and duration.&#160;

The assessment of pain relies mostly on methods that require a person to communicate. However, for people with cognitive and verbal impairments, existing ...

Applying Incongruent Visual-Tactile Stimuli during Object Transfer with Vibro-Tactile Feedback

The application of incongruent sensory signals that involves disrupted tactile feedback is rarely explored, specifically with the presence of vibrotactile feedback (VTF). This protocol aims to test the effect of VTF on the response to incongruent visual-tactile stimuli. The tactile feedback is acquired by grasping a block and moving it across a partition. The visual feedback is a real-time virtual presentation of the moving block, acquired using a motion capture system. The congruent feedback is the reliable presentation of the movement of the block, so that the subject feels that the block is grasped and see it move along with the path of the hand. The incongruent feedback appears as the movement of the block diverts from the actual movement path, so that it seems to drop from the hand when it is actually still held by the subject, thereby contradicting the tactile feedback. Twenty subjects (age 30.2 &#177; 16.3) repeated 16 block transfers, while their hand was hidden. These were repeated with VTF and without VTF (total of 32 block transfers). Incongruent stimuli were presented randomly twice within the 16 repetitions in each condition (with and without VTF). Each subject was asked to rate the difficulty level of performing the task with and without the VTF. There were no statistically significant differences in the length of the hand paths and durations between transfers recorded with congruent and incongruent visual-tactile signals &#8211; with and without the VTF. The perceived difficulty level of performing the task with the VTF significantly correlated with the normalized path length of the block with VTF (r = 0.675, p = 0.002). This setup is used to quantify the additive or reductive value of VTF during motor function that involves incongruent visual-tactile stimuli. Possible applications are prosthetics design, smart sport-wear, or any other garments that incorporate VTF.

We present a protocol to apply incongruent visual-tactile stimuli during an object transfer task. Specifically, during block transfers, performed while the hand is hidden, a virtual presentation of the block shows random occurrences of false block drops. The protocol also describes adding vibrotactile feedback while performing the motor task.

The application of incongruent sensory signals that involves disrupted tactile feedback is rarely explored, specifically with the presence of vibrotactile ...

A Standardized Method for Measurement of Elbow Kinesthesia

Proprioception is an important component of controlled movement. The threshold to detection of passive movement (TDPM) is a commonly used method for quantifying the proprioceptive submodality of kinesthesia in research settings. The TDPM paradigm has been found to be valid and reliable; however, the equipment and methods used for TDPM vary between studies. In particular, the research laboratory apparatuses for producing passive movement of an extremity are often custom designed by individual laboratories or inaccessible due to high cost. There is a need for a standardized, valid, and reliable method for measuring TDPM using readily available equipment. The purpose of this protocol is to provide a standardized method for measurement of TDPM at the elbow that is economical, easy to administer, and that produces quantitative results for measurement purposes in research-based settings. This method was tested on 20 healthy adults without neurological impairment, and eight adults with chronic stroke. The results obtained suggest this method is a reliable way to quantify elbow TDPM in healthy adults, and provides initial support for validity. Researchers seeking a balance between equipment affordability and measurement precision are most likely to find this protocol of benefit.

Here, we present a standardized method for measurement of elbow passive kinesthesia using the threshold to detection of passive movement (TDPM) that is appropriate for a research setting.

Proprioception is an important component of controlled movement. The threshold to detection of passive movement (TDPM) is a commonly used method for ...

Behavioral Assessment of Visual Function via Optomotor Response and Cognitive Function via Y-Maze in Diabetic Rats

The optomotor response and the Y-maze are behavioral tests useful for assessing visual and cognitive function, respectively. The optomotor response is a valuable tool to track changes in spatial frequency (SF) and contrast sensitivity (CS) thresholds over time in a number of retinal disease models, including diabetic retinopathy. Similarly, the Y-maze can be used to monitor spatial cognition (as measured by spontaneous alternation) and exploratory behavior (as measured by a number of entries) in a number of disease models that affect the central nervous system. Advantages of the optomotor response and the Y-maze include sensitivity, speed of testing, the use of innate responses (training is not needed), and the ability to be performed on awake (non-anesthetized) animals. Here, protocols are described for both the optomotor response and the Y-maze and examples of their use shown in models of Type I and Type II diabetes. Methods include preparation of rodents and equipment, performance of the optomotor response and the Y-maze, and post-test data analysis.

Neural degeneration in both eyes and brain as a result of diabetes can be observed through behavioral tests carried out on rodents. The Y-maze, a measure of spatial cognition, and the optomotor response, a measure of visual function, both provide insight into potential diagnoses and treatments.

The optomotor response and the Y-maze are behavioral tests useful for assessing visual and cognitive function, respectively. The optomotor response is a ...

Multimedia Battery for Assessment of Cognitive and Basic Skills in Mathematics (BM-PROMA)

Learning mathematics is a complex process that requires the development of multiple domain-general and domain-specific skills. It is therefore not unexpected that many children struggle to stay at grade level, and this becomes especially difficult when several abilities from both domains are impaired, as in the case of mathematical learning disabilities (MLD). Surprisingly, although MLD is one of the most common neurodevelopmental disorders affecting schoolchildren, most of the diagnostic instruments available do not include assessment of domain-general and domain-specific skills. Furthermore, very few are computerized. To the best of our knowledge, there is no tool with these features for Spanish-speaking children. The purpose of this study was to describe the protocol for the diagnosis of Spanish MLD children using the BM-PROMA multimedia battery. BM-PROMA facilitates the evaluation of both skill domains, and the 12&#160;tasks included for this purpose are empirically evidence-based. The strong internal consistency of BM-PROMA and its multidimensional internal structure are demonstrated. BM-PROMA proves to be an appropriate tool for diagnosing children with MLD during primary education. It provides a broad cognitive profile for the child, which will be relevant not only for diagnosis but also for individualized instructional planning.

Multimedia Battery for Assessment of Cognitive and Basic Skills in Mathematics BM-PROMA

BM-PROMA is a valid and reliable multimedia diagnostic tool that can provide a complete cognitive profile of children with mathematical learning disabilities.

Learning mathematics is a complex process that requires the development of multiple domain-general and domain-specific skills. It is therefore not ...

Standing Neurophysiological Assessment of Lower Extremity Muscles Post-Stroke

Transcranial magnetic stimulation (TMS) is a common tool used to measure the behavior of motor circuits in healthy and neurologically impaired populations. TMS is used extensively to study motor control and the response to neurorehabilitation of the upper extremities. However, TMS has been less utilized in the study of lower extremity postural and walking-specific motor control. The limited use and the additional methodological challenges of lower extremity TMS assessments have contributed to the lack of consistency in lower extremity TMS procedures within the literature. Inspired by the decreased ability to record lower extremity TMS motor evoked potentials (MEP), this methodological report details steps to enable post-stroke TMS assessments in a standing posture. The standing posture allows for the activation of the neuromuscular system, reflecting a state more akin to the system's state during postural and walking tasks. Using dual-top force plates, we instructed participants to equally distribute their weight between their paretic and non-paretic legs. Visual feedback of the participants' weight distribution was provided. Using image guidance software, we delivered single TMS pulses via a double-cone coil to the participants' lesioned and non-lesioned hemispheres and measured the corticomotor response of the paretic and non-paretic tibialis anterior and soleus muscles. Performing assessments in the standing position increased the TMS response rate and allowed for the use of the lower stimulation intensities compared to the standard sitting/resting position. Utilization of this TMS protocol can provide a common approach to assess the lower extremity corticomotor response post-stroke when the neurorehabilitation of postural and gait impairments are of interest.

This protocol describes the process for performing a neurophysiological assessment of the lower extremity muscles, tibialis anterior and soleus, in a standing position using TMS in people post-stroke. This position provides a greater probability of eliciting a post-stroke TMS response and allows for the use of reduced stimulator power during neurophysiological assessments.