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Changes in the Propofol-Induced Frontal Electroencephalogram in Children with Autism Spectrum Disorder

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Changes in the Propofol-Induced Frontal Electroencephalogram in Children with Autism Spectrum Disorder Changes in the Propofol-Induced Frontal Electroencephalogram in Children With Autism Spectrum Disorder The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Walsh, Elisa Claire. 2017. Changes in the Propofol-Induced Frontal Electroencephalogram in Children With Autism Spectrum Disorder. Doctoral dissertation, Harvard Medical School. Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:32676116 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA TABLE OF CONTENTS ACKNOWLEDGMENTS .................................................................................................. 2! ABBREVIATIONS ............................................................................................................ 4! ABSTRACT ...................................................................................................................... 5! INTRODUCTION ............................................................................................................. 6! Overview of General Anesthesia (GA) ................................................................................... 6! Molecular and Neural Circuit Mechanisms of Propofol ...................................................... 6! Use of the Electroencephalogram in GA and Brain Monitoring ......................................... 8! Overview of Pediatric Neurodevelopment ......................................................................... 10! Anesthesia-Induced EEG in Development and Aging ....................................................... 12! Overview of Autism Spectrum Disorder (ASD) .................................................................. 15! Pathophysiology of ASD ...................................................................................................... 16! Structural Changes in Autism Spectrum Disorder ............................................................ 17! Anesthetic Management of Pediatric Patients with ASD ................................................. 19! Hypothesis ............................................................................................................................ 19! SPECIFIC AIMS ............................................................................................................. 21! MATERIALS AND METHODS ....................................................................................... 22! RESULTS ....................................................................................................................... 29! Aim 1. To characterize the propofol-induced frontal EEG in ASD pediatric patients. ... 29! Patient population .............................................................................................................. 29! Differences in EEG power by age in ASD patients ............................................................. 29! Differences in EEG coherence by age in ASD patients ...................................................... 32! Aim 2. To investigate the changes in the propofol-induced frontal EEG power in ASD vs. NT pediatric patients. ..................................................................................................... 32! Patient population .............................................................................................................. 32! Modeling age-dependent EEG power in ASD vs. NT patients ........................................... 33! The trajectory of alpha (8-13 Hz) power by age differs in ASD vs. NT patients ................. 33! The trajectory of slow (0.1-1 Hz) power by age differs in ASD vs. NT patients ................. 36! Aim 3. To characterize the incidence of burst suppression and prolonged suppression in the propofol-induced frontal EEG in ASD vs. NT pediatric patients ............................ 39! Patient population .............................................................................................................. 39! Increased incidence of suppression events in ASD vs. NT patients .................................. 39! Clinical characteristics in ASD vs. NT patients experiencing suppression events ............. 40! DISCUSSION ................................................................................................................. 42! CONCLUSION ............................................................................................................... 50! SUGGESTIONS FOR FUTURE WORK ......................................................................... 51! SUMMARY ..................................................................................................................... 53! SUPPLEMENTARY FIGURES ...................................................................................... 54! CITATIONS .................................................................................................................... 57! ACKNOWLEDGMENTS I first want to thank my family and friends who have supported me throughout my career, especially my fiancé, Winston Yan and my mother, Ruth Walsh. Second, I want to thank the members of Harvard-MIT Health Sciences and Technology (HST) community who supported me throughout my medical training, including my thesis work. I want to extend my gratitude especially to Dr. Richard Mitchell, Dr. Matthew Frosch, Dr. David Cohen, and Patricia Cunningham. Third, I want to thank our collaborators at the Massachusetts General Hospital. Thank you to Dr. Timothy Buie, Dr. Sarah Kadzielski, and other pediatric gastroenterologists who graciously allowed me to collect my data in their endoscopy suite. Dr. Erik Shank, Dr. Paul Firth, and numerous other pediatric anesthesiologists were also invaluable resources in this setting. I am grateful, too, for our statisticians, Dr. Timothy Houle and Sara Burns, who helped to refine the power analysis by age contained within this thesis. Last but not least, I want to thank my thesis advisors, Dr. Patrick Purdon and Dr. Emery Brown, for their incredible mentorship. In the space of a single year, you’ve taught me more than I ever thought possible about not only the science, but also becoming an independent researcher and growing confidence in my own ideas. I am humbled for the opportunity to work with both of you, and am thrilled for the possibility of continuing our work together during my residency training. In the Neuroscience Statistics Research Laboratory (NSRL) as a whole, I have found such a creative, diligent, and incredibly intelligent group of people who am now proud to call my friends. Thank you for welcoming me into your family. I especially want to highlight Dr. Oluwaseun Johnson-Akeju and Dr. Ken Solt, who often served as mentors in both the research and clinical setting; David Zhou, who never failed to help me troubleshoot during data collection and analysis; Dr. Michael Prerau, whose impromptu chalk talks were some of the best teaching I have ever received on signals and systems processing; Johanna Lee, who performed the initial pediatric anesthesiology work and became a fast friend; Lauren Hobbs and Kara Pavone, who 2 aided in my orientation to the laboratory and submitting my first IRB; and finally, Sheri Leone, who makes everything in the group run like clockwork and has been one of my most treasured supports during the research year. 3 ABBREVIATIONS 5-HT = serotonin Ach = acetylcholine ASD = autism spectrum disorder BIS = bispectral index CNS = central nervous system DA = dopamine dB = decibels DR = dorsal raphe EEG = electroencephalogram E/I = excitatory/inhibitory GA = general anesthesia GABA = gamma aminobutyric acid Gal = galanin His = histamine HPD = highest posterior density hr = hour(s) LC = locus coeruleus LDT = laterodorsal tegmental area LH = lateral hypothalamus KCC2 = potassium-chloride co-transporter 2 m = minute(s) MRI = magnetic resonance imaging n = number of subjects NE = norepinephrine NKCC1 = sodium-(potassium)-chloride co-transporter 1 NMDA = N-methyl-D-aspartate N2O = nitrous oxide NT = neurotypical OR = operating room POA = preoptic area POD = post-operative delirium PPT = pedunculopontine tegmental area PSI = patient state index PV+ = parvalbumin-positive s = second(s) SMD = standardized mean difference TMN = tuberomamillary nucleus Vpag = ventral periaqueductal gray yr = year(s) old 4 ABSTRACT General anesthetic drugs induce characteristic oscillations within brain circuits that can be readily assessed using the electroencephalogram (EEG), allowing a controlled and noninvasive way to study the circuitry of the human brain. During propofol-induced unconsciousness, frontal EEG demonstrates large-amplitude slow- delta oscillations (0.1-4 Hz) and frontally coherent alpha oscillations (8-13 Hz), the latter of which are thought to reflect propofol’s actions within frontal thalamocortical circuits. Previous studies from our laboratory show significant age-related changes in the propofol-induced frontal EEG that are thought to reflect the development of underlying circuits mediated by GABAergic interneurons. Interestingly, autism spectrum disorder (ASD) is increasingly seen in the clinical setting and is thought to arise from deficits in GABAergic signaling leading to abnormal neurodevelopment and neuromodulation. To investigate differences in how ASD patients respond to the GABAergic
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