Neuromonitoring.com

I was fortunate to be able to attend the 7^th Leipzig Practical Course on Neuro-

The Kosmos

monitoring in Leipzig, Germany March 13-16.  Leaving good weather in Philly, I arrived in Frankfurt with piles of snow and hundreds sleeping on cots in the airport from cancelled flights the night before. Even the normally punctual German trains were delayed on the way to Leipzig.  But once I got there the next few days were educational and fun.

Leipzig is known for books and Bach.  The Leipzig Book Fair was going on in parallel making hotels hard to come by.  This Fair is a massive event for publishers, writers, readers, and publications and builds upon Leipzig’s centuries-old history in publishing.

Rudi and wine from the area around Inomed

 My trip happened on short notice and due to the Fair I didn’t have a hotel for the first night. I lucked out and found a room…the last one…in the Kosmos Hotel.  I like to stay in alternative places when possible as I see too many hotels where you know what your room looks like before you open the door.  The Kosmos was very much alternative; a bed, a chair, a bathroom in the hall…and that’s about it.  But that’s all I needed as I was out “paying homage to Bach” for much of the evening with Rudi Matmueller the founder of Inomed and Michael Malcharek who was running the course.

Inomed is a pretty cool German company that makes intraoperative monitoring equipment.  They aren’t in the U.S. yet, but look for them soon.

Bach

Leipzig is the home of Bach and I found a few hours to tour the Bach Museum.  Though small, it is very well done.  Once you go through it, you feel like you knew Bach and you knew the Leipzig he knew.  A highlight for me was the “orchestra wall” that lets you raise the volume of individual instruments of that era in a Bach orchestral piece so you can hear how it contributes to the overall sound.   I often think of multimodal neuromonitoring as an orchestra score for the brain.   Several instruments from Bach’s time as well as some of his original musical scores are on display and you learn how they deciphered who wrote what due to the inks and writing styles.  This museum is in contrast to the Haus Der Musik  in Vienna that I toured a few years ago.  Most musicians of these times eventually lived in Vienna so that museum is larger and covers the works of many musicians.

Michael Malcharek and Maja Rojic

Back to the reason I was there…the Leipzig meeting is one of the few focusing on neuromonitoring and was first organized by Dr. Michael Malcharek, a neuro- anesthesiologist in Leipzig.  He has had encouragement and support from colleagues and vendors including Rudi Matmueller, the president of Inomed.

The meeting covered the use of raw and processed EEG, evoked potentials during surgery, and intensive care monitoring.  As the name implies it is a very practical course providing hands-on experience using the monitoring modalities (furnished by various vendors) as well as a visit to an OR where monitoring is taking place.  I gave a workshop on multimodal neuromonitoring in the ICU and enjoyed many discussions with attendees during the frequent social functions.

Michael Dinkel

Gerhard Schneider

 I ran into friends I hadn’t seen in a while like Michael Dinkel who has been recording intraoperative evoked potentials for most of his career.  I also ran into Gerhard Schneider who I knew when he was “just a kid” running around the ORs in Munich with Professor Kochs.  Drs. Schneider, Malcharek, Dinkel and a few others have helped to maintain a focus on neuromonitoring at a national level in Germany in a time when other topics are getting the spotlight.

 My career has kept me focused on critical care for the past decade and a lot has developed in intraoperative monitoring that has passed me by.  This course provided a glimpse of some of the new techniques.  In an evening symposium Maja Rogic talked about  some fascinating work on recording motor evoked potentials from the cricothyroid muscles in order to better map the speech areas of the brain .  She did some of this work with Vedran Deletis, an old friend of mine who I hoped would be there.   They stick recording needles into the cricothyroid muscles through the skin. Ouch.  Then they stimulate transcranially (C3-Cz, see A below) to elicit a response.  The interesting thing is that you can’t get a motor evoked potential from a single stimulation in anesthetized patients like you can in awake patients.

To elicit MEPs, a short train of stimuli must be used to build up an excitatory postsynaptic potential and reach a firing threshold of the target motoneurons. The diagram below shows the path of the stimulation from the primary motor cortex, down the corticobulbar pathways, vagal nucleus, vagal nerve, and superior laryngeal nerve to the cricothyroid muscles. The response is shown as the superposition of four single MEPs from cricothyroid muscle.

So where does broccoli (from the title) fit in?  Maja has also been working on food recognition…something I have no trouble with. She did some interesting experiments in this area and presented the work for the first time at this symposium.  But since it’s so new, she asked that I not include it in this blog until the publication is accepted.  So you have to wait for the broccoli.

Abby, from Medlogic, demonstrates the Infrascanner 2000

The Infrascanner™ 2000, a hand-held, NIRS-based, device for detecting subdural hematomas, recently received FDA clearance.

The first showing of the product was at the ICU of the Future meeting in Los Angeles, February 21-22.  The technology inside this product goes back to the late Dr. Britton Chance, a brilliant biophysicist at the University of Pennsylvania.  I worked for Dr. Chance in 1972 while still an electrical engineering student at Penn building amplifiers for oxygen electrodes.  We re-connected a few decades later when we were both at an NIH workshop to assess neonatal neuromonitoring technology.  At that time Dr. Chance’s group had developed technology to use near infrared light to assess cerebral oxygen in a product called RunMan™.  Shortly after that, we got involved in some software development for the device that was being commercialized by a company called NIM run by Dr. Chance’s sons Sam and Peter.  We used RunMan as one of the measurements in our initial multimodal monitor prototype.

NIM never really got off the ground as a business and Dr. Chance’s technology was licensed by Infrascan, Inc a company in Philadelphia run by Baruch Ben Dor.  It seems Baruch’s team has finally gotten it across the finish line.  Baruch and I have known each other for several years as we both run small medical device companies.  We both had an unnecessarily prolonged time getting our products cleared by a dysfunctional FDA process (more on this in another post).

Clarence Carlos

A lengthy FDA experience translates into a period where you need to keep your company alive to benefit from your work but can’t sell your product for the income to do it. Knowing what we went through, I’m happy to see their product finally on the market.

A company called Medlogic, based out of Pittsburgh, is now selling the product. Medlogic is run by Clarence Carlos, a fascinating and amazingly connected person who I spent some time with in a bar in LA.  As a former football player he is developing the untapped sports injury market to quickly assess the brain following a blow to the head. He is working with school systems on a national level and already has the device in the hands of the Pittsburgh Steelers.  They are also exploring the obvious applications in pre-hospital and hospital care.

No hematomas in this brain

The current Infrascanner 2000 is easy to operate.  It provides a diagram of the head much like that seen on an EEG headbox with eight positions marked for you to test, four left and four right.  The device steps you through collecting a measurement at each site by holding the unit to the head and pressing a button…very easy. This pattern supposedly will provide a quick assessment of the presence of subdural hematomas across the cortex.  I tried the unit myself.  My do-it-yourself scan was quick and easy and found no hematomas!

Sunny Miami was the location of the annual meeting of the American Clinical Neurophysiology Society (ACNS), Feburary 5-10.  The heater in my house (in Philadelphia) broke a month before the meeting so the 80 degree warmth made this meeting even more enjoyable. And many attendees from New England were in Miami as their houses were getting buried by the blizzard that weekend. Just before landing in Miami I looked out the window of the plane and saw the house where I grew up (see photo).  It’s still there in Hollywood Beach…but now surrounded by towering condos.  So this meeting was coming home for me.

Hollywood Beach – Arrow is where I grew up

I hadn’t been to the ACNS meeting in several years and this one was very refreshing. I remember the days, not so long ago, when you had to drag EEG folks kicking and screaming to get them to look at any kind of processed EEG.  The argument was always that you would miss events.  But in anesthesia and critical care back then, we were hearing “Wow, look what I can see.”  So it was heartening at this meeting to see the wholesale adoption of processed EEG by the main EEG society in the U.S.  Their justification is that continuous EEG is warranted in many ICU patients but the manpower to read all the EEGs is lacking (and the quality of life of the readers is decreasing according to Dr. LaRoche). So processed EEG is being proposed as a fast screening method but coupled with detailed reading of selected periods of raw EEG. This makes sense.  And according to Cecil Hahn (Sick Kids) 30% of ICU EEG folks already use quantitative EEG in their practice.

Drs. Bej and Legatt at Mango’s 

 

At this year’s meeting there was quite a focus on neuromonitoring in the ICU, both adult and neonatal.  The day-long ICU Course on Thursday was standing room only with about 150 attendees.  The Presidential Lecture by Dr. Susan Herman was on continuous EEG in the ICU.  There was a session on quantitative EEG in neurocritical care and a special interest group meeting on ICU EEG Monitoring.  And at the end of the meeting, with still a good-sized audience, there was a symposium on continuous EEG monitoring in neonates.

Discussing whether seizures really exist with Dr. Gotman

Starting out the ICU course, Dr. Heman said it seemed at times like the only criteria for continuous EEG (cEEG) monitoring in the ICU was that the patient had a head.  She urged more thought be put into criteria for monitoring so that the limited resources could be provided to the most critical patients.  In a subsequent talk, she said we should focus more on whether seizures are causing other problems (such as what can be see with other monitoring modalities and imaging) and not just that there are seizures.

Dr. Wustoff (Stanford) noted a good use of cEEG is for observing sleep/wake cycles in neonates which are very useful in outcome prognostication. Dr. LaRoche talked about the “gray area” in determining seizure from non-seizure and to think of this a more of an ictal-interictal continuum.  She also mentioned the importance of the clinical history, imaging, and simultaneous metabolic events that can be seen with multimodal monitoring.

EEG interpretation suffers from the same subjective interpretation pervasive in many areas of medicine.  You ask five neurologists to read an EEG and you get six interpretations.  To counter this, and to address the different nature of EEG in critical care, a standardized terminology for ICU EEG was developed.  The work started in 2005 and was endorsed by the ACNS in 2012. Larry Hirsch described the 7-year effort to develop the terminology.  The terminology is very much needed in order to gain consistency in describing ICU EEG.  But a question from the audience was quite telling:  Do we now have to write two reports:  one with the new terminology, and one that all of us can understand (based on our past training)?   This is expected when terminology changes.

Drs. Wustoff, Shellhaas, Tsuchida on the Beach

The neonatal session at the end of the meeting covered progress in developing a standardized terminology for neonates similar to that for adults.  Drs. Wustoff (Stanford), Shellhaas (U Michigan), and Tsuchida (Washington) along with Dr. Clancy (CHOP) presented this work.  I had the pleasure of heading to South Beach with the docs for lunch and some needed beach time before heading back north.

Suzette LaRoche (Emory) reported on the Critical Care EEG Monitoring Research Consortium (CCEMRC) Multicenter Database. The goal is to develop a standardized and an efficient means of data entry for clinical research. I’ll be reporting on the CCEMRC in an upcoming blog.

If you have an EEG showing a seizure and you want to get rid of it you can choose to consult a neurologist or an engineer.  The neurologist will give an anti-epileptic drug.  The engineer will run the EEG recording through software filtering to take out spikes and the rhythmicity.  Both approaches get rid of the seizure!  But the clinician gave the patient a toxic drug and the engineer didn’t touch the patient.  Who did the most good for the patient?  I kept thinking about this as I was hearing some of the presentations.  Nick Abend (CHOP) endorsed my feelings when he said whether seizures cause worse outcomes is still an open question…though recent work is starting to support that they do.

Chuck Yingling with Denise Bates

Though this blog doesn’t focus on intraoperative monitoring (there are other forums for this topic) it was good to see many of my friends working in this area such as Marc Nuwer, Alan Legatt, and Chuck Yingling.  I had the opportunity to head to Mangos on South Beach a few times with friends.  Though Mangos is a bit touristy and maybe a bit risqué for conservative folks, it is one of the best places to see the Latin culture in Miami.  The dancing up on the bar (a new set about every 15 minutes) is amazing.   I managed to take a few friends there over the course of the meeting.

I also had some time to visit nearby Haulover Beach.  It is one of the few official clothing optional beaches in the US and it’s always packed with people taking various degrees of that option.  I grew up just north of that beach and generally go there when European friends are visiting.  They are fine with it, but being a true American, I was taught it’s a sin to look at naked people, so I always wear eye patches…and sometimes I wear them on my eyes.

The next meeting of the ACNS is in Atlanta in February, 2014.

The Neurotrac

I had my first colonoscopy a while back and having had very few surgeries in my lifetime I thought this would be an interesting time to experiment with some “depth of anesthesia” technology.  A product that my pals Gary and Matt and I developed back in the 1980’s (the Neurotrac), had a number on it called the spectral edge frequency (SEF). The SEF was computed from the EEG and indicated the highest frequencies active in the EEG.   The product was the first digital system made for recording and processing continuous EEG in the OR and ICU.  The SEF was sensitive to anesthetic drug action as this edge tends to go through a repeatable change from light anesthesia to deep anesthesia. The Neurotrac was quickly used in studies of depth of anesthesia by academic sites around the world.  So I have followed this field from nearly the beginning.

Aspect Medical Systems was the first company to raise venture capital and fund major investigations into developing a single number that reflected depth of anesthesia and that was independent of the type anesthetic agent.  They were a very cool company with a scientist, Nassib Chamoun, at the helm. The number they computed, called the bispectral index (BIS) pretty accurately monitored the depth of anesthesia and sedation.  They manufactured a small box and sensors to allow anesthesiologists to monitor anesthetic drug action directly, rather than indirectly through vital signs.  It was not without its critics as with any new technology, but it has become a mainstay in many institutions to make sure surgical patients do not wake up during surgery nor suffer the side effects of too much anesthetic.

So…back to my experiment.  The day before the colonoscopy I grabbed an Aspect monitor from the company (we were doing several projects for them) and brought it home for the notorious “night before”.  This is where you take some laxatives and drink a week’s worth of water in an hour until you literally explode with the worst case of colon blow you’ve ever had.  It’s a mess but it does improve the view for the GI docs looking for those pesky polyps.

The day of the ordeal, I put the BIS monitor in a canvas bag and headed into the hospital.  I was “processed” the same as every patient but they saw the bag and said I had to leave my clothes in a locker.  I told them this was a brain monitor and that I wanted to hook myself up and monitor my depth of anesthesia.  It was apparent they had never had this conversation before as they didn’t know how to answer.  The attendant said this wasn’t allowed, but I asked him who was going to monitor my brain…if I didn’t.   He never heard this either.  So he excused himself, returned about ten minutes later and said it was OK.  I asked what had changed his mind.  He said he talked to the head anesthesiologist who ran this out-patient clinic.  As luck would have it, she remembered me when I was a medical student at this same hospital, told the resident that I was a bit “different”…and to just let me do what I wanted.

I entered the room, with my paper gown on (opening to the rear), and put on the BIS sensor and plugged in the monitor.  I had a nice conversation with the nurse anesthetist who was very cooperative and as curious as I was as to what this would show.  He put in an IV line and, I got into position on my side, and watched the display.  I was going to see at what number I blanked out.  The highest value of BIS is 98 so that’s where it started drawing the trend line.  He started to push the Propofol, I felt a slight stinging as it entered and I had no sooner looked at the number when…“poof”….I was out.

I woke up at the end of the procedure to see a perfect “bathtub” curve, as they call it, on the display:  a nice induction followed by a relatively stable surgical level and then a mirror of the induction for the recovery (see the picture).

BIS during my colonoscopy

Monitoring the brain makes a lot of sense when you are giving “poisons” that target the brain (as one anesthesiologist described his profession)…and it has amazed me that there was such an initial resistance to monitoring the brain (which is a reason I’m not retired by now).  In spite of this, anesthesia has done a remarkable job of promoting safe practice, probably more so than any other specialty in medicine.  Their Closed Claims Project is similar to the investigation of plane crashes that has made flying so safe.  I have followed that project since its early days with the work of Dr. Karen Domino.

Members of the anesthesia community have policed themselves to where they are the model for other specialties.  It keeps their butt out of trouble and my butt safe.  I like that.

The Neurocritical Care Society arranged a joint meeting with ANIM in Mannheim, January 23-27, 2013.  ANIM is the Arbeitstagung  NeuroIntensiv- und Notfallmedizin which is the Workgroup on Neurointensive and Emergency Medicine.

A few of the attendees at ANIM

There were two days with NCS sponsored sessions including two on neuroscience nursing.  ANIM was interesting and a lot of fun. It did not let me down in terms of seeing and leaning new stuff and it provided ample social opportunities to share a beer with old and new friends…my definition of an excellent meeting.

Nursing

The nursing sessions brought together nurses from the US and Germany to discuss and compare nursing issues.  Each speaker in the morning session was balanced by one from the other country.  From the U.S. were Mary Kay Bader, Cindy Bautista, Susan Yeager, Karen March, DaWai Olson, Sarah Livesay, and Sheila Alexander.   Cindy gave a nice overview of neuromonitoring from Yale’s perspective.  I learned that Yale-New Haven is now the fourth largest medical complex in the US.  And DaiWai, to his credit, even made the German attendees laugh.  I attended most of these sessions as I firmly believe the future of neuromonitoring in critical care is going to be influenced significantly by neuroscience nurses.  I also attended their morning session because it had a great breakfast spread…and I was doing some “late night reporting” for this blog the night before and had to go from bed to lecture very quickly the morning of the symposium.

Meeting

Dr. Werner Hacke listening to The Codes and Dynamite

Gene Sung (President of NCS) and Werner Hacke (Heidelberg) opened the joint meeting.  There were several topics related to neuromonitorng.  Peter LeRoux gave a nice overview of multimodal neuromonitoring. Jed Hartings talked about monitoring cortical spreading depressions and his COSBID research group.  Jan Claassens talked about the importance of monitoring EEG.

One of the highlights was Stephan Mayer’s talk on the Future of Neurocritical Care…”Where’s My Tricoder”.  He reviewed the specs for the Star Trek Tricoder, the gizmo that Dr. McCoy used to heal all illnesses in the TV series.  He reminded us that we already have amazing technology today such as the Hemedex CBF monitor, the Neuroptics pupillometer, microdialysis, Licox, and many other “futuristic” technologies.  Of course the part of his talk I liked best was when he asked who really invented the Tricoder.  His next slide was of me, our multimodal monitor, and scenes of the Burning Man art festival…and he claimed I invented it during one of my trips (no pun) to that alternative festival in the desert.  Well, of course I didn’t invent the Tricoder, but I did make a solar powered smoothie machine for Burning Man and made smoothies for those walking around in the desert looking at art.  I plan to make it controllable by EEG and have applied to DARPA for funding (the subject of a future post).

There were several neuromonitoring related posters.  Stephen Spainhour and DaWai Olson presented a poster showing how misleading manually recorded ICP values (as seen in the medical record) can be for research projects due to their irregularity and the fact that they may not reflect reality.  My guess is that this applies beyond research and for more than ICP.  Their work is enlightening and supports the rationale for connected devices and continuous data collection.

A neurocritical care meeting would not be complete without a performance by the Codes.  They were followed by Dynamite, rumored to be Dr. Hacke’s favorite band.  They were the awesome.

Social Activities

Dr.s Sakowitz and Unterberger

Neurosurgeon sandwich

I’ve always learned more outside of the lecture hall and this was true at ANIM.  Heidelberg was nearby and served as a focal point for entertainment. As many know, the castle in Heidelberg has the world’s largest wine barrel…….so we were off to a good start.  There was a tour of Heidelberg one evening for the nursing contingent.  One evening I ended up at a dinner with the speakers and organizers…obviously because of my press credentials for this blog.  It was in a typical quaint Heidelbergerish restaurant with long benches and tall glasses. It was hosted by Andreas Unterberg (head of neurosurgery at Heidelberg). I got to know Oliver Sakowitz, another neurosurgeon at Heidelberg. I experienced a rare “neurosurgeon sandwich” at the meeting (see picture) as I sat between two of them. On the right is Carla Jung (Heidelberg) and on the left is Dortja Engel (St. Galen). My smile shows you how much I like sandwiches. I would marry both of them if I were 30 years younger…and believed in marriage…so I had to settle for sharing some beers.  But I did enjoy some snowboarding with Doortja the following week in Davos.

Drs. Varelas and Hanley standing under Pan

Dr. Hartings and Unidentified Friend

Dr. Sakowitz, Dr. Stone (retired), Dr. Shutter, Dr. Hartings

In the afternoon of the last day we were bussed to Schwetzingen Palace and Gardens which date back to the 1300s.  We started the afternoon in a brewery next to the palace. The alcohol served as a neuroprotectant had anyone slipped on the ice during the ensuing 2-hour garden tour.  Despite the winter weather and some of the statues being boxed up, the gardens still proved magnificent and the stories about Carl Theodore, one of the residents in the 1700s were fascinating. We then toured the palace where you got a real sense of life in these times.  Then, of course, more beer in the neighboring brewery and the bus trip home.

I found another focal point of “learning” was the lobby bar at the Maritim Hotel where many attendees were staying.  Lisa the bartender gets credit for keeping track of the circles of chairs that would form and re-form as conversations and groups shifted through the evening.

Next year ANIM is in Hannover January 22-25, 2014.  I don’t think they will have the joint session with NCS…but I believe they are trying to organize another joint meeting in the future.  If they do…I recommend it!