Ep. 178: Interpreting emergency EEG in suspected non-convulsive status epilepticus

00:00:00: Welcome to IANcast, your weekly source for education, research and updates from the European Academy of Neurology.

00:00:16: Welcome to IANcast, Weekly Neurology.

00:00:19: My name is Justyna Babrodska and I'm the head of the Pediatric Neurology Department at the Medical University of Silesia in Katowice, Poland.

00:00:26: I'm also a member of IANs Scientific Committee.

00:00:29: The topic today is Interpreting Emergency EG in Suspected Non- convulsive status epilepticus.

00:00:35: My guests today are very well-known epilepsy experts.

00:00:40: At the beginning, I would like to introduce Professor Stefan Rüick, a neurologist specialized in epileptology, neuro-intensive care, and autoimmune encephalitis, and the head of the Epilepsy and Sleep Unit at the University Hospital of Basel in Switzerland.

00:00:56: And the second guest is Professor Markus Leitinger, a neurologist, neuro-intensivist, a neurophysiologist, head of the EEG lab at Salzburg University Hospital, Christian Doppler University Hospital.

00:01:10: Dear guests, thank you for joining us today.

00:01:16: My first question is about the prevalence of non-Calvasi statoepilepticus.

00:01:21: First, let me ask Professor Riegg.

00:01:24: There's not an exact number about that, but we estimate that non-conversive status epilepticus encompasses about forty percent of all status epilepticus and status epilepticus is about nine to fifteen cases per ten thousand.

00:01:43: It's a rough estimate because you don't have exact data especially about the non-conversive status epilepticus because you can only difficultly diagnose it.

00:01:56: So perhaps Markus has done a study on the epidemiology in his city.

00:02:03: I think he has more precise data.

00:02:05: Yeah, thank you, Stefan.

00:02:07: quite interesting thing.

00:02:08: And thank you for pointing out the prevalence as it appears in the emergency department.

00:02:13: We have in fact done a study and a population based study where we could focus on the whole encatchment area of our hospital.

00:02:25: And when the total number of status epilepticus is about thirty six per a hundred thousand adults, it's about the twelve per hundred thousand are non-combustive status whereas the twenty four per hundred thousand is prominent motor phenomena.

00:02:45: I totally agree with you Stefan because when we did this study and it was from two thousand ten to two thousand fifteen then the NCC criteria diagnostic criteria were introduced in two thousand and thirteen and what we could see was an increase exactly in that year.

00:03:03: that when you provide adequate criteria, then people dare to say, yes, this is non-convulsive status.

00:03:09: And this happens when you have the availability, the availability of criteria fosters the diagnosis and gives clinicians a safe feeling to do this.

00:03:26: Yes, I can only add then to the difficulties not only the criteria but we need essentially the EEG and we looked even that not only the EEG is necessary but that you have enough time to record with the e.g.

00:03:43: to diagnose the non-conversive status epilepticus.

00:03:46: and we did a small study in our hospital more than almost fifteen years ago where we could show that the use of longer recordings markedly increased the detection rate of non-conversive status epilepticus.

00:04:02: Yeah, that's fine.

00:04:03: So in our hospital we tried to accentuate the use of continuous EEG, which is now in a rather satisfying progress.

00:04:16: And the continuous EEG, let's say, twenty-four hours is very available in this detection of non-convulsive seizures.

00:04:28: There is another point I would like to mention is that two helps to B score.

00:04:32: That means when you have one hour recording, Then there are a few features with which you can calculate the total score, and this helps you to estimate the probability of occurrence of seizures or status in the next twenty-four hours.

00:04:49: What do you think about this?

00:04:51: Now that's absolutely helpful score of our colleagues, established and we use it too to look whether how is the probability of catching non-conversive status.

00:05:06: Perhaps you can say what is the content of the health to be with which perhaps you can shortly mention.

00:05:13: for those that are not so familiar with the or we look after and tell later moment.

00:05:23: Yeah, thank you for giving me the opportunity to say this.

00:05:29: So first of all, it's very helpful that this score can be entered online.

00:05:34: That means if you just enter two as a number, helps, then again, two as a number and B, and there were score, then you are immediately connected to an automated calculator, which provides you with the essential opportunities.

00:05:54: Just to give you a short.

00:05:56: idea of what is asked there.

00:05:58: It's first a brief potentially ichthyrhythmic discharges that is birds.

00:06:04: You know that there are potential birds and definite birds according to AC&S.

00:06:10: And you can obtain two points here.

00:06:13: So this is a very important criterion.

00:06:15: Then it's the presence of lateralist parodic discharges, lateralist rhythmic delta activity, or bilateral independent parodic discharges.

00:06:25: which lead to one point.

00:06:27: Another point you can earn with prior seizures or sporadic epileptiform discharges or a frequency of more than two hertz of any periodic or rhythmic pattern.

00:06:39: You know that the American Clinical Neurophysiology Society, that is ACNS criteria, also provide criteria for the plus features like plus F, the fast frequencies.

00:06:54: or plus R, which is rhythmic activity, or plus S with rhythmic delta activities with superimposed pathways.

00:07:05: So this group also earns one extra point.

00:07:09: And for example, if you have just one point, then you have which means that you have a twelve percent risk of a seizure and the recommended length of additional CIG monitoring is twelve hours.

00:07:26: So this core helps us a lot to to gauge the resources and to decide who should be recorded with a continuous CIG.

00:07:36: Exactly, and I think we should now underscore a little bit as I note a little bit in my framework that the Diagnosis of non-conosy status epilepticus can be done affirmatively only by having a knee-gear recording.

00:07:53: Because clinically, even after thirty-five years looking at these people, you can really sometimes be very convinced that must be non-conosy status epilepticus.

00:08:06: You put on the recording and you see only severe encephalopathy.

00:08:11: I think these two entities, the non-canals if status epilepticus and encephalopathy, they are really a continuum with a large gray land in between where the expertise of the EEG reader is still absolutely necessary to compare clinical in clinical science with the electro encephalographic traces or patterns.

00:08:37: There is a very practical issue I would like to discuss with you.

00:08:41: So, for example, we hook up or we provide a montage to a patient and then we make the recording.

00:08:49: We find a very abnormal eG.

00:08:52: that means there is a slowing in background, maybe some discontinuity even, and there are some periodic patterns.

00:09:01: And we are aware that this pattern might be on the ectal-inter ectal continuum.

00:09:08: So we think that it is quite helpful to do an intravenous anti-seizure medication trial.

00:09:17: Because if you do it adequately, you get really an idea of whether this pattern might respond or might not respond.

00:09:24: What is your experience with this approach?

00:09:28: Yes, that's a very good approach.

00:09:31: There are two things also I would share with my audience.

00:09:35: The first thing is the usual emergency treatment of suspected status epilepticos or especially of established status epilepticos is the first line as benzodiazepine and.

00:09:49: Unfortunately, some of the patterns that may indicate an encephalopathy also reacts to the benzodiazepine.

00:09:57: This is the form called triphazic waves.

00:09:59: Now it's generalized periodic discharges with triphazic morphology.

00:10:05: But if you give them a trial with the benzodiazepine, both a pletiform discharges and this GPDs with triphazic morphology disappear.

00:10:17: And for that reason, we sometimes start with a really big shot of leviteracetam, because that's a pure or more pure anti-seizure medication, also very quickly acting and looking how the trace reacts to that, because that would not be an anti-seizure medication effect.

00:10:42: That's a very, very important point.

00:10:44: Thank you for bringing this up.

00:10:46: And I love to hear that you use this approach as well.

00:10:53: Because, you know, there was a small group who asked themselves how to approach these patients with an IV-ASM trial.

00:11:04: And we really made a table or a diagram which allows for officially to start with and the seizure medication in this IV diagnostic asm trial, especially in patients who have already decreased level of consciousness, where you assume that this further decreases when you apply or administer and benzodiazepines, or in a patient group where people have respiratory suppression, then you assume that this even worsens when you give benzodiazepines right now.

00:11:40: So you may start with ASM, but be careful.

00:11:43: It's only for this diagnostic that's diagnosed, you have to say twice, diagnostic IV, ASM trial, and not for purely state-disabled optical treatment, not for state-distributed or for diagnostic trial.

00:11:56: Absolutely, that's a very, very important point because in the last ten years we saw that the... Guidelines are absolutely clear how to treat step-by-step status epilepticus and there are so much violations that the benzodiazepines are not given or too late or they are only in second place and there are too low dose.

00:12:17: Of course if a patient is already in critical state with his respiratory functions then it would be quite challenging to administer benzodiazepines.

00:12:29: but on the other hand benzodiazepines in almost almost every larger study are underdosed because we fear that respiratory suppression.

00:12:41: Most of the studies show that the sufficient use of benzodiazepines saved lives.

00:12:51: In the very early trial from Eldridge with the benzodiazepine out hospital, the respiratory problems were bigger in the group, which received placebo than in the group that received eight milligrams of lorazepam.

00:13:09: I think that's also another point to keep in mind with the benzodiazepine on the benzodiazepine trial.

00:13:17: But as a trial for non-conversive studies at BLABticos, I think that's an interesting thing to do without benzodiazepine.

00:13:25: Thank

00:13:27: you for pointing this out, because people really are afraid of giving too much, but the patient may even get worse.

00:13:36: without an efficient and efficacious treatment.

00:13:41: Yeah, that's a great message.

00:13:44: A great take-home message.

00:13:45: Please do not undergo spancidiocepins in case of status treatment.

00:13:53: Stefan, do you have a pocket card in use in your hospital?

00:13:59: It's not a pocket card is worse.

00:14:01: It's a leaf or a booklet, a very small booklet that fits the pocket of our assistance.

00:14:07: We did it with another hospital together and it's quite used and there are also blind copies around in Switzerland and even in southern Germany of this.

00:14:17: little booklet where we say a little bit how we proceed with diagnosing and especially treating the status epilepticals.

00:14:26: because some guideline or some guidance, because it's not a guideline, it's a guidance for young doctors coming to neurology and doing first calls and so that's important to have.

00:14:41: Have you considered to publish this small book in order to write?

00:14:47: No, because it's a little bit, say, experience-based or eminence-based.

00:14:52: It's really not evidence-based and it was quite tricky to have it here around in Switzerland without, say... as good as well evidence based as possible.

00:15:07: but everyone can have the PDF of that that we should really really revise it because it's from twenty nineteen and so Yeah, but I think we should a little bit return to the electrophysiology because I think the podcast is rather on diagnosing or on EEG when I remember right the title of our podcast and not say the treatment of status epilepticos, which both of us like to discuss about.

00:15:41: Stefan, just to tell you that we provide a pocket card.

00:15:45: not about treatment, but about the criteria in EEG reading.

00:15:49: And this one has been published recently in epileptic disorders.

00:15:55: It is not, maybe not a big deal, but I think those who want to use it can use it.

00:16:02: It's among the supplemental material.

00:16:05: It's the how to diagnose status epilepticus.

00:16:09: And just it's really, it's not something famous or something like this.

00:16:14: or the beginners, it might be helpful.

00:16:16: And if you could have a look at it and provide me feedback at some time, I would be very happy.

00:16:24: Because this leads us exactly to the point.

00:16:27: We have the criteria.

00:16:30: Who of both of us should give the listener the audience a short overview about the criteria?

00:16:41: Would you be so kind?

00:16:43: Oh, you correct me if I'm incorrect, because Marcus Lighting, he published that in Lancen Neurology, one of the most famous papers in epileftology in the last ten years.

00:16:54: So it's the so-called Salzburg criteria, because we met at the colloquium and we found that the diagnostic, there's some aporea, and we do not well with diagnosing and criteria, as Marcus mentioned earlier, would be very, very helpful.

00:17:14: This group of experts established these so-called Salzburg criteria and Marcos validated that in an internal and external cohort.

00:17:25: So that's a very important thing.

00:17:29: It's a flow chart at the end.

00:17:34: it starts always with the clinical suspicion of a non-conversive status epileptic cause.

00:17:39: and if you have clear epileptic form discharges and they have frequency above the two point five.

00:17:46: That's an established or that the diagnosis of non-conversive status epileptics can be made.

00:17:53: If the frequency is below these two point five cycles per second or Hertz per second, then there is a lot of criteria.

00:18:04: you can look at them and if they are present or not present that.

00:18:08: leads you to either to the non-conversive status epilepticus or to the possible non-conversive status epilepticus or that excludes or makes it very unlikely that you have non-conversive status epilepticus.

00:18:25: There are four criteria when you're below this.

00:18:28: two point five frequency of epileptic discharges.

00:18:34: per second, then we mentioned already or discussed for a long time the IVID trial, so you try intravenous anti-seizure medication and look if there is a response.

00:18:48: And the best or the clearest response is not only that the EEG normalizes or speeds up or these charges disappear, but also that the patient clinically improves.

00:19:03: because that's the fascinating.

00:19:05: on non-conversy status epilepticus.

00:19:09: Likely, comatose or non-responding patient, you give him something what we call a somnifair, this benzodiazepine, and the patient awakes.

00:19:18: It's like a paradoxical reaction.

00:19:20: So that makes you very, very confident that the patient who awakes after giving or having administered benzodiazepines, it must be, and that's clearly Stasis Epilepticus.

00:19:34: There is no other disease that patients awake upon the... the administration of benzodiazepines.

00:19:41: Then if you see in a longer recording, in the next ten, twenty minutes, you see a spatiotemporal evolution that you have a spread of epileptic discharges to other brain regions, you have, say, also increase in... you have a decrease in frequency and what you call a seizure, then it would be also very pointing that this is non-conversive status epilepticus, because status epilepticus is not only a permanent epileptic form discharges, but also short seizures.

00:20:22: Within them, the patient does not recur to a normal state.

00:20:28: the rise of short seizures very close together also makes the diagnosis of a non-convalescent and also from the convalescent status epilepticus.

00:20:40: Then if you see subtle ectal clinical phenomena on a patient, some twitching with the eyes or so, that can be correlated also a little bit with the EEG, that also points to the presence of a non-conversive status epilepticus.

00:20:58: However, when you have only fluctuations a little bit in frequency, of your waves and you don't have clear really discharges and you have no evolution say really at a special expansion of your of your activity or you don't have really frequency changes that are clearly definite then that would not feel the fulfill the criteria for.

00:21:26: definitive non-conversive status epilepticos, but for possible.

00:21:30: And then you can look whether you do then an IV, IED, ISM trial and looking whether he reacts or not.

00:21:40: If it reacts clinically and electroencephalographically, then it would also be a non-conversive status epilepticos.

00:21:47: If there's no reaction on the trial with an IV and decision medication, then it remains possible.

00:21:57: And if you have a very static pattern, which is sometimes a little bit rhythmic, but not really rhythmic, no evolution, no spatial, no, neither temporal evolution, then this is only encephalopathy and this is not non-conversive status epilepticus.

00:22:17: I hope I've summarized a little bit the criteria.

00:22:22: Oh, that's fantastic.

00:22:23: Really, thank you so much for this.

00:22:26: I just want to have a question because when I was younger...

00:22:33: Still young.

00:22:34: Thank you so much.

00:22:36: I just wanted... I was a bit confused by the term possible status.

00:22:40: Really.

00:22:42: However, I think that the ACNS approach is very helpful.

00:22:47: They say that possible status is something like ictal and ictal continuum, which means you have to do something to find out.

00:22:55: So possible means doesn't mean it's the result of something, but it's the start of giving a diagnostic ID, AS, and trial.

00:23:03: So do something when there is something in doubt or something possible.

00:23:07: So the final result should be ideally yes or no.

00:23:13: But I understand the possible status means it's on a continuum where you do not know exactly right from the beginning what this pattern means.

00:23:24: Do you see it in a similar way or totally differently?

00:23:29: No, absolutely.

00:23:30: And possible status epilepticus is something to me that is moving or can move.

00:23:35: It's nothing static.

00:23:37: So either it turns back to a pure and careful path and then i think time is important also in in in possible status epilepticus.

00:23:46: this is not saying one second of an eeg and then you say it's possible status epilepticus but you have a pattern over time say the next ten minutes.

00:23:56: if nothing happens it remains.

00:23:58: if some birds came up or some special temporal evolution then it turns towards definitive non-conversive status epilepticos, or it turns to encephalopathy.

00:24:13: Possibly it's quite an unstable or transient state of something, because you cannot be, I think, seventy-two hours impossible state of epilepticus.

00:24:25: so possible state of epilepticus needs a decision and the decision can be administer an IV ASM and looking if it reacts or not.

00:24:34: and then this pushed you out from possible to encephalopathy.

00:24:39: if the patient reacts then.

00:24:41: It pushes to N-C-S-E, I think.

00:24:44: Also, the ictal continuum is this gray land or this epileptic gray land between encephalopathy and status epilepticos.

00:24:56: Oh, that's fantastic.

00:24:57: That's very brilliant wording and descriptions.

00:25:02: Regarding the seizures, I was asked, for example, If you have one seizure pattern, one evolution pattern in twenty-four hours, it's the status.

00:25:14: And I think that the ACNS gave a clear answer, so it should be above twenty percent of the recording.

00:25:22: So this twenty percent are right, a good sensitivity, specificity approach where you really are confident with being on the right track.

00:25:32: Not overestimating, but also not underestimating.

00:25:35: What do you think, please?

00:25:37: Yes, that's important, but sometimes practically it can be challenging to determinate the twenty percent with certainty.

00:25:46: Of course, if it's fifty or sixty percent, you are not in doubt and then you will think at least it's... Anyway, it's status epilepticus, because it's so frequent.

00:25:58: But being around the same with the twenty percent to discriminate between fifteen and twenty-five, I be used and persist and looking to if you can see a pattern, whether that is about a fifth of the recording that is in the equal state.

00:26:17: So that's maybe helpful.

00:26:21: to use these technical helps of semi-automated EEG analysis.

00:26:28: Although they cannot diagnose, to my opinion, non-conversive status epilepticos because they are really not fit enough to look at the artifacts and many, many patterns are, I think, not recognized by these softwares.

00:26:47: Great.

00:26:49: There was just one more important point I would like to make is that when we teach our newcomers at our department, then we really forced them to have a check of cerebral imaging and laboratory and also drug levels, let's say lithium or so, to integrate all medical and paramedical data.

00:27:16: to interpret the EEG.

00:27:19: You know, when you have a patient in acute renal failure or severe hepatic failure, then patterns may arise that are really on the gray zone between stages and encephalopathy.

00:27:33: However, both acute renal failure and others may cause a status.

00:27:40: But we are more reluctant.

00:27:43: if we have a true metabolic explanation for a specific eG pattern, we maybe go a bit step back, keep it all the picture, and we also give diagnostic IVAs and trial, but we are more reluctant to say why are these aggressive status if the underlying etiology may by itself explain the eG pattern.

00:28:08: Is that a useful approach?

00:28:10: What do you think?

00:28:12: Yes, as I said, I think the whole picture is always the patient, his paraclinical values, say, imaging and lab values, and you have to take in account, and that makes it so, so difficult.

00:28:26: if you have a comatose patient with severe organ or multi-organ failure, and then comes up, is this status epilepticus?

00:28:36: That can be really, really challenging, because if the patient, for example, severely obtunded by high oremia or high ammonia, and then he closes his eyes.

00:28:49: You cannot say he opens the eyes and then it's clear status and closed is not status.

00:28:54: You can't absolutely say that, but it's usually true in almost otherwise healthy patients going into status epilepsy.

00:29:02: So you have really to be very, very careful.

00:29:05: what is the egg and what is the chicken.

00:29:08: So also also a little bit what causes what.

00:29:10: And sometimes it can be very, very difficult.

00:29:14: And at the end, I think we try to treat both of them.

00:29:20: Say, if you have renal failure, you will be really looking that the values are that you have hemodiliesis or something like that.

00:29:29: And you give trial of anti-seizure medication to look whether that works and the patient improves.

00:29:38: Very well.

00:29:42: I would like to address one point.

00:29:46: That means if we have to give a recommendation to our young colleagues, what is the literature?

00:29:57: that we could start on.

00:29:59: So maybe each of us gives one literature recommendation.

00:30:04: My one is my personal one, but maybe you start,

00:30:07: but no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no,

00:30:10: no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no.

00:30:28: epileptic form discharges.

00:30:30: It's about critical care, e.g.

00:30:32: terminology.

00:30:33: If you have gone through this paper with the many, many pictures you can see there, it's really a good starting point.

00:30:40: What do you think?

00:30:41: Absolutely.

00:30:41: It's the same thing.

00:30:43: The first day in the EEG, they get a little small book of papers that they have to read on.

00:30:50: One is the ECNF classification.

00:30:53: The other one is the Salzburg criteria, of course, because that's very, very an important thing to diagnose the most difficult EEG patterns, I think, or the EEG condition, the non-canalcystatus epileptico.

00:31:10: really essential papers, then also the help to be scored.

00:31:14: It's very well written paper because it's very helpful, very practical and very easy to administer.

00:31:20: So I think that's my my trios or my trilogy of papers that the residents should read when they start the EEG because in our rotation, they go also on the ICU, and they like to do that because it's a very fascinating world, I think, for neurologists and for neurophysiologists to be there with these very special patients and the very special patterns of EEG, so you can see there.

00:31:50: That brings into my mind that also patients after cardiac arrest might benefit from a clear EG diagnosis.

00:31:59: So they have found in the Telstar trial that patterns that are not just periodic, but those who might fulfill these criteria might, in a subgroup analysis and so on, that they might benefit at the end of the day.

00:32:15: So I think this is an open issue.

00:32:17: And just to tell you that the EG in the post-hypoxic patients, I've done a work together with Peter Stefano, a systematic review of myclonus, and there we found out that in a collective with an existing well-responding background, it's the background that drives the outcome and not so much the presence of a mic-like phenomena.

00:32:45: And it could be, it was a subgroup of twenty percent CPC one or two, which is quite good.

00:32:51: And in this subgroup, right?

00:32:54: And Pia and Nikolai Gaspar have done another work together, and they could prove this in their cohort in up to twenty-five percent.

00:33:03: So each year will make sense.

00:33:05: Also, it's better to do more each year than less when you can interpret it and give it a chance to interpret it.

00:33:14: is also on non-neurological ICUs.

00:33:17: Let's say a medical ICU where patients of the cardiac arrest are treated and cared for.

00:33:23: So also there the EEG has its well established place, I think.

00:33:29: Absolutely.

00:33:30: Also to my opinion, and it's not only a diagnostic tool, it's also a prognostic tool or cancer for partly assist in doing a neuroprocrastication and the exact handling and knowing the pattern on sort of evolution that patients of the post-anoxic cardiac and several of the cardiac arrest have.

00:33:53: That's very important for people working on the neuro or on the ICU.

00:33:59: and what is also very important is that the EEG has to be.

00:34:05: interpret very carefully in the first eight hours after the cardiac arrest, because there is very old data, but sound data that there can be even a flat line EEG and people can really recover because the first six, eight hour the brain is really in turmoil.

00:34:24: And after between eight and twenty four hours, you get really already very decisive patterns and also some prognostic information.

00:34:35: and then you look together with the other modalities, how will be the prognosis of the patient after cardiac arrest?

00:34:43: Stefan, I think we should wrap up.

00:34:46: Maybe each of us says two to three points or more as you like.

00:34:52: Just to take home message.

00:34:53: What is the most important thing that people should remember of our dialogue now?

00:34:58: or a recommendation or whatever you like?

00:35:00: So just say, So what is the final summary of our talk?

00:35:04: Okay, if you do EG on an ICO or looking at non-conversing status epilepticos, read the ACNS paper to see all the patterns you can have with big and good examples.

00:35:19: that will help you a lot.

00:35:22: Thank you.

00:35:22: So please remember there are four criteria.

00:35:26: Epileptic form discharges more than two point five hertz or twenty five per ten seconds.

00:35:32: per screen, usually, or epoch, as we say, clear clinical spatial temporal evolution.

00:35:40: Both of them are called electro-graphic status.

00:35:44: And in the group of electro-clinical status, we have a time-locked clinical correlate.

00:35:49: That means, for example, a jerk, but it can also non-motor phenomena, like an ictal blinking of the eyes.

00:35:56: You see light flashes.

00:35:58: And the second one is... e.g.

00:36:02: and clinical response due to a diagnostic IV-ASM trial.

00:36:09: One word, be careful.

00:36:11: The clinical response may officially occur up to twenty-four hours after the IV-ASM administration.

00:36:21: That means maybe you have to wait a few hours or ask the next day.

00:36:26: This is also relevant not to say it's not in the first five seconds.

00:36:30: We can take this.

00:36:31: And your guests, okay?

00:36:33: Thank you for this fantastic discussion and thank you for your presence today.

00:36:37: Thank you.

00:36:38: Thank you, Stefan.

00:36:39: It was a great pleasure.

00:36:40: Thank you, Markus.

00:36:40: It was a great pleasure, too.

00:36:42: Greetings to Salzburg.

00:36:44: Greetings

00:36:46: to Basel.

00:36:46: Greetings to Poland.

00:36:54: This has been EANcast Weekly Neurology.

00:36:56: Thank you for listening.

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00:37:23: That's ean.org backslash membership.

00:37:28: Thanks for listening.

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