Diplomate, American Board of Psychiatry and Neurology

Tom, Here is the case. I will send a hard copy with signed release via snail mail. -HK

Brainmaster Case Study

Date: August 26, 2009

Submitted by: Harry Kerasidis M.D. Diplomate, American Board of Psychiatry and Neurology Diplomate, American Board of Sleep Medicine

RE: HARRIN0009 DOB: 04/3/1985

History: This patient presented to our clinic in October 2008 as a 23 year old woman with chronic residual cognitive deficits and sleep disturbance as a result of a head injury that she sustained 10 years earlier. She had a traumatic head injury in 1998 (age 13). She was struck by a truck while riding at minibike and dragged for a long distance. Glasgow Coma scale 3 on admission to the ER. She was in coma for about 6 ½ weeks. She had a partial right temporal lobectomy, and a ventriculostomy during her acute care. She was eventually transferred to Kennedy Krieger and gradually cleared 10 months. She had a very slow recovery with gradual recovery of speech, she eventually returned to school with IEP accommodations and past all of her competencies for graduation from high school. A primary complain, in addition to her cognitive deficits was hypersomnolence during this time. She tried Adderall XR 20mg for both the hypersomnolence and Provigil 200mg daily. These medications helped a little with her hypersomnolence. Since graduating she has started at the Center for Life Enrichment and has gotten a part-time job and seemingly her lethargy has improved. She struggled with short term memory, word retrieval problems, mild expressive problems, impulsivity, multi-tasking, and difficulty with concentration. In the past she was treated with Aricept, which seemed to help for a few weeks and then lost effectiveness. She has been taking Paxil 20mg since age 16mg. At the time of her initial evaluation she endorsed intermittent feelings of sadness. She has sleep onset insomnia of up to a couple of hours duration. This would worsen with stress, anxiety, and frustration with her disabilities.

Exam: Mental Status: She was alert and oriented x3, memory 3/3 at 5 minutes, she could name the current president, and spell WORLD forwards and backwards. Cranial Nerves II-XII: were intact. Motor strength testing: 5/5 throughout with normal bulk and tone, no pronation drift. Sensory: intact to the primary and cortical modalities. Cerebellar: without nystagmus, appendicular or midline ataxia. Reflexes: 3+ in the left arm and 2+ on the right, 3+ in the legs bilaterally. Babinski was present on the left.

MRI of the brain demonstrates encephalomalacia and gliosis involving the lateral right temporal lobe, anterior right frontal lobe, superior bi-lateral frontal lobes with associated thinning of the corpus callosum and mild diffuse volume loss.

QEEG demonstrates increased beta activity over the left fronto-temporal region with significant increased broadband asymmetry in bilateral fronto-temporal regions (see attached). LORETA analysis demonstrates increased 9-25hz activity in the left frontal and temporal lobes.

Treatment/Training Protocol Procedure:

After her initial evaluation, imipramine 50mg at bedtime in addition to the Paxil 20mg daily that she was already taking to help with sleep and attention. She complained of palpitations and sweats and so the imipramine was decreased to 20mg and maintained at this dose for the duration of the treatment.

4 channel Live Z-score training %-ZOK at F3, C3, T4 and C4 for 30 minutes each session was initiated January 26, 2009. She attended these sessions regularly about once per week, sometimes 2 times per week.

Results: At her first follow-up approximately one month after starting neurofeedback (after 4 sessions), she had not noticed any significant improvement in her condition. She continued to complain of migraine-like headaches and vitamin B2 400mg daily was recommended for headache prevention. She was seen again in follow up approximately 3 weeks later (7 sessions) and she and her mother reported significant improvements in her memory and environmental awareness. She continued complaining of migraine-like headaches and had not yet started the vitamin B2. By her next follow-up June 10, 2009 she had completed 20 neurofeedback sessions. She reported a significant improvement in her sleep patterns. She reported that not only was she able to fall asleep faster, but she could easily return to sleep if she woke up in the middle of the night. She and her mother reported continued increased awareness. He mother described the effects as: “It’s as if my daughter has been waking up from a deep sleep”. In fact, her increasing awareness brought her to increased awareness of her cognitive deficits and how much “wasted” time had gone by leading to some emotional sense of loss. This was addressed with counseling. On the other hand, she also began showing awareness of the future and began planning further educational activities. She had started the vitamin B2, and reported that her headaches had decreased by about 80%. She continues weekly sessions and reports steady improvement of her memory and cognition. A follow-up QEEG is pending.

Baseline QEEG Eyes Closed

Amplitude Asymmetry

Delta Theta Alpha Beta LORETA

9-25hz