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In some, generalized spike-wave bursts may be precipitated by arousal stimuli, similar to the K complex. In some patients, especially in children who tend to have "spiky" K complexes, it may be difficult to differentiate between the two. These features were studied in detail by Niedermeyer, who introduced the concept of "dyshormia," in which primary generalized spike-wave bursts and K complexes share the same generating mechanism, producing generalized burst activity. The patient also had more irregular polyspike-wave bursts during stage 2 sleep (B). With exception of the spikes, the epileptiform bursts had similar wave form and distribution with K complex induced by noise (B). This is followed by generalized spike-wave bursts, which become progressively slower in frequency and less rhythmic toward the end of the seizure. A history of absence seizures coexists with or precedes myoclonic seizures in about one third of patients. The ictal pattern is indistinguishable from interictal epileptiform activity in most cases, but may have a greater number of polyspikes with higher amplitude and with a more rhythmic sequence. Three types of myoclonus have been proposed: (i) cortical reflex, (ii) reticular reflex, and (iii) primary generalized epileptic myoclonus. It should also be noted that myoclonus often occurs without detectable epileptiform activity. Atonic Seizures Atonic seizures are characterized by sudden loss of muscle tone, often associated with drop attacks, and lasting only a few seconds. Note the decrease of muscle artifacts during spike and wave bursts indicating the decrease of muscle tone. The chaotic high-amplitude slow-wave activity may be intermittently replaced by a relatively low-amplitude pattern (partial flattening) lasting a few seconds. Typical hypsarrhythmia is common in younger infants, and over time, the degree of abnormality tends to lessen to produce more organized activity with greater synchrony and symmetry and lower amplitude. The evidence of multifocal and scattered spikes are better visualized by eliminating slow waves using a shorter time constant (0. Etiologies are diverse and include hereditary metabolic disorders, intrauterine infection, cerebral dysgenesis, tuberous sclerosis, hypoxic encephalopathy, etc.
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The wiring procedure may be repeated until successful wire access to this zone is achieved and confirmed by retrograde angiography in two orthogonal views. During this manoeuvre, the operator must be keenly aware of the retrograde guide position (which will tend to push out of the coronary ostium), the distal wire tip (which will have a tendency to retract backwards) and the tip of the microcatheter as it advances through the collateral. With any manipulation of this system, all three of these components are affected, the changes to which must be anticipated by the operator and promptly rectified. Care must be taken to avoid over rotation of the microcatheter to avoid microcatheter fatigue (first encountered with the Corsair device); this phenomenon which presents as resistance to wire movement within the microcatheter must be recognised early and promptly remedied (by microcatheter replacement). At this stage, the retrograde wire is withdrawn and exchanged for a long externalisation wire. Prior to the introduction of equipment antegrade along the externalised wire, the retrograde microcatheter must be retracted into the distal target vessel. It is critical that full microcatheter coverage of the guidewire within the collateral vessel is maintained to prevent collateral laceration. It is crucial to anticipate this guide movement and fully disengage the retrograde guide while the microcatheter is retracted. Failure to do so may result is serious injury to the ostial or proximal donor vessel. Following this manoeuvre, a new retrograde Penetration or Nagivation-group wire is used to traverse tissue planes to enter the same plane as the antegrade wire. Capture must occur on the soft end of the wire to avoid wire entrapment within the snare. Finally, using a simultaneous push-pull technique, the antegrade guide is advanced along the snared wire to capture the retrograde microcatheter (resident in the aortic root) and seat the antegrade guide back into the ostium of the target vessel. The wire is then carefully liberated from the snare, withdrawn and changed for an externalisation-group wire as previously described. Next, the retrograde guide is fully disengaged and pulled out of the field of view. With the guide held in this position, the retrograde microcatheter is carefully retracted to the origin of the collaterals used for the procedure. A retrograde guide is re-engaged and an angiogram is performed to confirm collateral integrity and to exclude meaningful injury. These procedures are learned in an iterative fashion, with early experience best developed under the mentorship of expert operators. As with early angioplasty, our developing understanding of the techniques and tools used to tackle this challenging lesion subset is likely to result in increased success rates and further improvement in clinical outcomes for our patients. Changes in myocardial ischemic burden following percutaneous coronary intervention of chronic total occlusions.
