NV: Doctor, if you have already requested a home electroencephalogram test, could you tell us a little about your experience and what are the advantages of exams performed at home?
Dr. DSJ: Yes. It is a very interesting question because we have advanced a lot in technological development and information management. I see that in the future, data processing and artificial intelligence will be tools that we will see more and more often. Recently, the International Federation of Neurophysiology released guidelines on the minimum standards required to perform an ambulatory electroencephalogram. We were consulted through the American Society of Neurophysiology (USA) to give our opinion as experts. In particular, I am in favor of performing ambulatory tests, due to the advantages they have over hospital tests. Perhaps in the future, it will no longer be necessary to hospitalize a patient for diagnostic purposes. We would have a more realistic scenario and common conditions for all patients, without sacrificing the quality of the record. We are even seeing that the video capacity that can be installed on a home basis also has a very good quality. And that there’s no such thing as “those tests are too dubious.” Or whether or not events can be captured.
I believe that there are not only financial or economic reasons but also many benefits for those events that are little known and take time to define. These records may be longer and a standard test may not necessarily be one performed in a hospital with 20 minutes of artifacts, but rather record the patient under natural conditions. In the future, if we add more elements, it will probably also help predict when a patient may or may not have a seizure. Perhaps it is not unreasonable to think that in the future, in addition to a diagnostic electroencephalogram, we may have more sensors, the so-called clothing sensors, to detect changes in frequency, if the patient is more sweaty, or if it is likely that he is starting to show abnormalities. So that you can anticipate a treatment, intervention, or going to a hospital.
The advantages of an ambulatory electroencephalographic study are working with a large amount of data and increased diagnostic capacity. There is no age limit. They also offer the opportunity to analyze more variables under increasingly natural conditions.
This will be available, I hope, as early as next year, internationally with the highest authority, for these minimum technological requirements.
NV: What are the protocols for this type of diagnosis?
Dr. DSJ: Protocols are core parts. And a protocol can only be done with a minimum number of electrodes needed. We still have a discrepancy between what the American Society for Clinical Neurophysiology recommends, which is a series of electrodes, and the International Federation, which says there should be approximately 21 electrodes. I believe it is between 16 and 21. There is still disagreement, mainly in Latin American countries, about which is the best, but I think this is the first step to take. It is necessary to increase the protocol’s number, which is more and more common, so that data can be transmitted and information shared. That would offer more opportunities.
More channels can be added to the electromyography, to see if there is an extra event, depending on the age. However, the most important are still those 16 to 21 channels of the standard assembly for electroencephalography. In other words, what we want to do is bring home the hospital environment, what is done there in an identical way, without sacrificing quality. That’s why there are minimum standards. If there were maximum standards you could argue, “why not put more electrodes?” but the patient couldn’t tolerate more.
It also depends on the patient’s condition, because there are also electrodes that are dense. After all, I think what we’re looking for is for the minimum requirements to be standardized first and for a video to be included. Because video also makes a difference not only in the settings of the electrodes that are captured but also in what is being viewed.
It does have some privacy questions. Imagine having a permanent video camera and being able to see family dynamics? How the family reacts to events. Even if it’s a non-epileptic event, you also have information about what can be done, how to react, and why you have these dynamics. Maybe it’s not just necessary for the epileptologist to assess what he’s seeing in the video, maybe it also helps the psychiatrist, or a psychologist, to say, “well, these conditions are really beyond what neurology can offer in a traditional way”.
NV: Can all patients have access to these exams at home?
Dr. DSJ: This has much more to do with the availability of features and services. Because machines these days are very portable. In addition, the preparation that a technician does – guiding family and patient, indicating what care they should have and the dates they should come – are not complicated at all. Only one indication and one protocol are required.
This has more to do with the country’s culture, availability, and also the paying agent. We must remember that these are longer studies. If someone says: “the culture of technological advancement that cardiology has, with implants that can be placed under the skin, and that monitor you for months and months, why not follow a few days of electroencephalography?!”
NV: Doctor, have the research dynamics currently changed due to the pandemic?
Dr. DSJ: It seems to me so. Research has changed and has changed a lot. I am currently General Coordinator of the Annual Congress of our Mexican Academy of Neurology, where all the country’s neurologists and child neurologists meet. And what I’ve seen, based on the last few years before the pandemic and now, is that there is indeed a clear interest in studying the complications, manifestations, and treatment of COVID in the nervous system, both central and peripheral. It completely dethroned cerebrovascular diseases and neurodegenerative diseases from the top. Probably because we were all aware that we not only had the uncertainty of how the virus would affect the nervous system initially but also now the wave of complications that we have: neurological and psychiatric, for millions and millions of patients who have been exposed.
Including what we initially thought was part of the diagnostic criteria, such as anosmia, or the inability to smell or taste. There are patients who have not recovered. Therefore, we also have the challenge of monitoring and thinking about the interventions we have to make in these patients. Because the senses of smell and taste are important even for sexual aspects, it is involved in everything. In other words, it’s not just for eating well, but for other functions related to smelling a person, a flower… Feelings have something to do with it. So, yes, it has changed dramatically. It has completely displaced and occupies approximately, according to statistics, 30% of all searches related to the nervous system.
NV: How was your experience assisting COVID patients, especially patients diagnosed with epilepsy?
Dr. DSJ: It is a very pertinent question for the present times. At first, there was a lot of uncertainty about how the SARS-Cov2 virus would affect patients with epilepsy. Or whether patients would develop epileptic seizures for the first time and later, epilepsy. Being on the front lines of hospital management during the pandemic, I had the opportunity to care for patients with epilepsy. Because it happens regularly and there are patients with uncontrolled epilepsy.
Fortunately, we did not see an increase in the number of hospitalizations, nor a greater lack of control than expected for a patient who already has a diagnosis. However, there were also patients that we saw who developed epileptic seizures for the first time.
There is still controversy over how much the virus can affect the central nervous system, especially neurons in the brain, but electroencephalographic studies have helped to try to identify these patients. Regardless of whether the clinic is an important element when diagnosing a patient with epilepsy or epileptic seizures, it must be considered that it is not so easy in this context. Because patients have hypoxia, that is, lung function is one of the most affected organs. For this reason, critically ill patients cannot easily access routine studies, as is often the case with patients who are evaluated for the first time for epileptic seizures.
In a global context, we have seen that stress, isolation, and lack of access to conventional drugs to control epilepsy are what is leading to the lack of control of seizures in patients diagnosed with epilepsy.
NV: How was the elaboration of the safety protocol guide for the performance of neurophysiological tests?
Dr. DSJ: The elaboration of the guides was an initiative of mine, as a Mexican, because I was observing that the waves, as they continue to happen, had a continental origin. We had the opportunity in Latin America to predict what was happening in Europe at that time, for the first wave. We were passively waiting for the same thing to happen here, as spectators. But fortunately, together with colleagues from Latin America and especially Dr. Texeira in Brazil, which is also a continent leader in neurophysiology, we organized a group of experts to prepare these guides in record time.
We had the unconditional support of the International Federation of Clinical Neurophysiology to develop them. With the vision of experts in each technique, not only electroencephalography but also sleep studies, polysomnography, neuroconduction studies, and muscle ultrasound. All areas should be protected, both patients and staff.
We work internationally in Latin America, as well as transcontinentally, where vaccines did not yet exist, therefore the safety protocol was not easy to achieve so quickly. The work we did during the day was replicated in Europe at another time, that is, 24 hours a day. This made it possible for the guides to be ready in record time, at the right time so that we had the opportunity to get to know them and avoid deaths, even among health professionals. Unfortunately, Mexico is not very well positioned in terms of the number of healthcare professionals who have died in this pandemic, but we can say that, at least in clinical neurophysiology, I am not aware of anyone who has passed away.
I believe that the guide protects not only the patients but also those who are providing the services, and also help decide how measures could be taken, based on what we had at the time and share with the world. This was initially shared in our native language, Spanish, but was not disclosed because the publication was done in English. Therefore, in parallel, although the Federation publishes it in English for the world to know, there is another version that had the support of the Mexican Academy of Neurology.
We went from place to place, sharing mainly with those who are part of the technical staff because not everyone speaks English, but they should read it. It wasn’t something optional, nor was it scientific, it was meant to protect us. And then, with the knowledge, we started to have conversations and demands, such as not being able to do a study because the guide said that the patient cannot hyperventilate. We changed the culture of doing a standard EEG because patients are no longer hyperventilated or exposed to titration from a breathing device, etc. That is, there is much more care.
There is a Spanish version that is unique in Mexico and Latin America and the international version, which is part of the guidelines that have been replicated by Canadians and international societies, such as those for epilepsy, sleep, or those that need it.
NV: How was the EEG test used in the development of this research and which EEG test indicators were most important?
Dr. DSJ: This is a very important element in assessing whether the clinical response is consistent with what is being given in therapy. In other words, evaluate the expected effects. The electroencephalogram is a key tool to see abnormal activity in the brain, especially in patients with epilepsy. In this type of study, what is done is a previous record for diagnostic purposes in order to determine: where is the abnormal area, how often, and if there are more areas to stimulate.
With that, we can work with a tension map and decide: we can stimulate these points, to get to this area, that is, make a personalized mapping. And these same elements, which seem abnormal, can be confirmed with an EEG after treatment. To see if there is a reduction in the amplitude, frequency, or if there is any change in the frequencies of the series.
The study can tell us that yes, a biomarker can decrease in frequency and therefore can also translate into clinical improvement. Or it can give us information about the connectivity between one electrode and another and say that brain frequencies change. And if they change at the same time they are out of sync. And if they get out of sync, then it can no longer be as abnormally disorganized as in epilepsy.
NV: How has your experience working with Neurovirtual equipment?
Dr. DSJ: Neurovirtual electroencephalography equipment, which I had the opportunity to not only experience technically because I learned how to assemble and disassemble it, but also as a specialist interpreting the quality of the studies is extraordinary.
They are functional, flexible, and easy-to-use devices that allow them to be moved virtually wherever they are needed without any limitations in data handling. Equipment that was questioned before, because they were files considered special, heavy, and that offered inadequate quality. The truth is that it is a device that meets all international requirements, but also many individual preferences. In that sense, there is flexibility. In addition, it allows the diagnosis of neurological diseases to the best standards, so it is indicated for these studies.
It is likely that, like other existing companies, it will have more and more advances and functions, but as it stands until now, it is a development that, from my personal and scientific point of view, meets the highest quality requirements and standards.